When a patient is experiencing oliguria, what action should the nurse take first?

When a patient is experiencing oliguria, what action should the nurse take first?

• A. Request an order for diuretics
• B. Assess for bladder distention
• C. Increase the patient's intravenous fluid rate
• D. Encourage caffeinated beverages

Answer: (B)

Assessing for bladder distention is the most appropriate first action when a patient is experiencing oliguria. Oliguria, defined as reduced urine output, can be caused by a variety of underlying issues, including urinary retention. By checking for bladder distention, the nurse can determine if there is a physical blockage preventing urination, which may require immediate intervention such as catheterization. This action allows for a more targeted approach to addressing the cause of oliguria. For example, if distention is present, resolving that issue could potentially restore normal urine output. Other options, such as requesting diuretics, increasing intravenous fluid rates, or encouraging caffeinated beverages, may be considered later based on the assessment findings, but they do not address the potential immediate physical cause of the oliguria. Thus, the assessment of bladder distention is a critical step in the nursing process that informs the next steps in management.

Assessing for bladder distention is the most appropriate first action when a patient is experiencing oliguria. Oliguria, defined as reduced urine output, can be caused by a variety of underlying issues, including urinary retention. By checking for bladder distention, the nurse can determine if there is a physical blockage preventing urination, which may require immediate intervention such as catheterization.

This action allows for a more targeted approach to addressing the cause of oliguria. For example, if distention is present, resolving that issue could potentially restore normal urine output.

Other options, such as requesting diuretics, increasing intravenous fluid rates, or encouraging caffeinated beverages, may be considered later based on the assessment findings, but they do not address the potential immediate physical cause of the oliguria. Thus, the assessment of bladder distention is a critical step in the nursing process that informs the next steps in management.