A postoperative client has not voided for 8 hours and reports lower abdominal discomfort. Which action should the nurse take first?
1Explain that delayed voiding is common after surgery and reassess in 2 hours.
2Assess bladder distention and obtain a bladder scan according to protocol.✓ Correct answer
3Insert a straight catheter to drain the bladder and relieve discomfort.
4Instruct the client to increase oral fluid intake to stimulate voiding.
Explanation
Option 2 is correct because eight hours without voiding plus lower abdominal discomfort requires prompt assessment for postoperative urinary retention; palpate for distention and obtain a bladder scan according to protocol before choosing an invasive intervention. Option 1 is incorrect because waiting another two hours can worsen bladder overdistention and injury. Option 3 may be required if significant retention is confirmed and an order or protocol permits it, but catheterization is invasive and should follow assessment. Option 4 is incorrect because oral fluids do not immediately relieve an already distended bladder and may be inappropriate if the client has fluid or oral-intake restrictions.
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 Practice GuidePostoperative elimination care includes intake/output, bladder assessment, pain control, mobility, and catheter avoidance when possible.
CautionUntreated retention can overdistend the bladder.
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.