A postoperative client has not voided for 8 hours and report… | MyMerci
EliminationBCC
Question
A postoperative client has not voided for 8 hours and reports lower abdominal discomfort. Which action should the nurse take first?
1Restrict fluids for the rest of the shift.
2Assess bladder distention and obtain a bladder scan according to protocol.✓ Correct answer
3Tell the client urinary retention is expected and no action is needed.
4Insert an indwelling catheter permanently.
Explanation
Postoperative urinary retention should be assessed promptly. The nurse should assess for bladder distention and use a bladder scan according to protocol before further intervention. Permanent catheter placement is not a first action and increases infection risk.
In-depth explanation
Clinical Judgment Retention is a comfort, kidney, and infection-prevention issue; assess before invasive action.
Memory Tip No void plus discomfort: scan the bladder.
Clinical scenario
Clinical Practice Guide Postoperative elimination care includes intake/output, bladder assessment, pain control, mobility, and catheter avoidance when possible.
Caution Untreated retention can overdistend the bladder.
Key concepts
Urinary Retention — Inability to empty the bladder adequately.
Bladder Scan — A noninvasive ultrasound estimate of urine volume in the bladder.
Bladder Distention — Stretching of the bladder due to retained urine.