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一位個案在接受脊髓麻醉後8小時。導尿管稍早被移除，個案表示恥骨上壓力持續增加但無法排尿。完成臨床判斷陳述。

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The nurse should suspect ::선택::postoperative urinary retentionexpected urinary elimination with no follow-up neededfluid volume excess as the only explanationurinary incontinence, ::선택::compare the bladder-scan result with the approved postoperative retention protocoldiscard the scan because bladder volume cannot guide careselect one universal catheterization threshold for every facilitywait until the next shift without further assessment, and ::선택::use protocol-directed intermittent decompression or notify as required, then reassessforce several liters of oral fluid despite the distended bladderinsert a prolonged indwelling catheter automatically for every postoperative clientapply firm repeated pressure over the bladder.

護理師應懷疑 ::선택::術後尿滯留預期的排尿功能，無需追蹤僅以體液容積過量作為唯一解釋尿失禁，::선택::將膀胱掃描結果與已核准的術後尿滯留處理方案進行比較捨棄掃描結果，因為膀胱體積無法引導照護為每個機構選擇一個通用的導尿閾值等到下一班再評估，不做進一步處置，並 ::선택::依方案進行間歇性減壓或依規定通知，然後重新評估儘管膀胱已脹大，仍強迫飲用數公升口服液體自動為每位術後個案插入長期留置導尿管對膀胱施加用力且反覆的壓力。

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