The nurse is caring for a client with a history of urinary r…

The nurse is caring for a client with a history of urinary retention related to prostate enlargement.  Urinary retention is currently being treated with an indwelling foley catheter.  The nurse assesses that the urine output is 45 ml per hour. The most appropriate nursing action is?

A 47-year-old patient was admitted to the medical surgical u…

A 47-year-old patient was admitted to the medical surgical unit this morning with progressive weakness and difficulty walking that began 10 days ago. The patient reports a recent respiratory infection two weeks ago and has a history of influenza vaccination last month. On assessment, the patient demonstrates bilateral lower and upper extremity weakness, shallow respirations, and diminished breath sounds. Diagnostic results include: Cerebral Spinal Fluid (CSF) protein: 190 mg/dL (Normal: 15–45 mg/dL) Cerebral Spinal Fluid (CSF) WBC: 3 cells/mm³ (Normal: 0–5 cells/mm³) ALT: 85 U/L (Normal: 7–56 U/L) AST: 72 U/L (Normal: 10–40 U/L) Serum creatinine: 1.6 mg/dL (Normal: 0.6–1.2 mg/dL)  Which nursing action is the priority for this patient?