The patient has a goal of maintaining urinary output of at least 80 mL/hour as part of the nursing care plan.
However, the patient's urinary output for the shift was only 20 mL/hour.
What is the appropriate action of the nurse?

Choice B rationale

Reinserting a urinary catheter requires a physician's order as it is an invasive procedure that falls outside the scope of independent nursing practice. Catheterization carries risks of infection and trauma, necessitating medical authorization.

Choice D rationale

Administering a medication, even a mild stool softener, requires a physician's prescription. Nurses cannot independently prescribe or initiate medication therapy. This intervention is based on a medical order to manage or prevent constipation.

Choice A rationale

Calculating fluid intake and output is a routine nursing assessment and monitoring activity that nurses perform independently to evaluate a patient's hydration status and kidney function. It does not require a physician's order.

Choice C rationale

Encouraging fluid and fiber intake are independent nursing interventions aimed at promoting healthy bowel function. Nurses can educate patients and suggest lifestyle modifications without a direct physician's order.

Choice E rationale

Assessing the abdomen for distention, bowel sounds, and tenderness is a physical assessment skill that nurses use independently to gather data about a patient's gastrointestinal system. It is a part of the nursing assessment process.

Choice A rationale

Nausea and vomiting after narcotic pain medication, while uncomfortable, are often expected side effects. The nurse should address these symptoms with antiemetics or other comfort measures, but this is generally not the highest priority unless the vomiting is severe or leads to dehydration or electrolyte imbalance.

Choice B rationale

A constipated patient needing to use the toilet should be assisted promptly for comfort and to prevent further complications. However, this need is generally not life-threatening and can usually be addressed after more urgent issues.

Choice C rationale

A patient waiting for discharge teaching is important, but discharge planning can typically be done once the patient is stable and other immediate needs are addressed. While timely discharge is a goal, it is not the priority when a patient is experiencing acute distress.

Choice D rationale

Chest pain and shortness of breath after nitroglycerin administration are signs of potential serious cardiovascular or respiratory compromise. Nitroglycerin should relieve chest pain; if it persists or worsens with shortness of breath, it could indicate worsening angina, myocardial infarction, or an adverse reaction to the medication. This situation requires immediate assessment and intervention as it poses an immediate threat to the patient's well-being.