Question

A 98-year-old patient with benign prostatic hyperplasia has a markedly distended bladder and is agitated and confused. All the following orders are received from the emergency department health care provider. Which order should the nurse act on first?

1) Draw blood for blood urea nitrogen (BUN) and creatinine.
2) Administer lorazepam (Ativan) 0.5 mg.
3) Insert 16 French retention catheter.
4) Schedule for IVP.

Answer 1

In this scenario, the nurse should act on order 3) Insert 16 French retention catheter first. Addressing the distended bladder is a priority to relieve the patient's discomfort and prevent further complications associated with urinary retention

Answer 2

The nurse should prioritize inserting a 16 French retention catheter to relieve the distended bladder of a 98-year-old patient with benign prostatic hyperplasia, which is the most urgent concern for preventing further complications such as acute renal failure.

Step-by-step explanation:

The order the nurse should act on first for a 98-year-old patient with benign prostatic hyperplasia who has a markedly distended bladder and is agitated and confused is to insert a 16 French retention catheter. This is a priority because it addresses the patient’s immediate need to relieve bladder distention, which can lead to further complications such as urinary retention and acute renal failure. The focus is on stabilizing the patient and preventing any additional strain on the kidneys due to the backed-up urine.

The other orders are also important but follow after alleviating the acute issue. Drawing blood for BUN and creatinine will help assess the renal function; however, it is not the immediate concern. Administering lorazepam (Ativan) could help with agitation but should not precede addressing the cause of discomfort, which might be the full bladder. Scheduling for Intravenous Pyelogram (IVP) is a diagnostic procedure and comes later in the plan of care.