# A postoperative client has not voided for 8 hours and reports lower abdominal discomfort. Which action should the nurse take first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394133&lang=en  
> language: en  
> subject: Elimination  
> category: BCC

## Question

A postoperative client has not voided for 8 hours and reports lower abdominal discomfort. Which action should the nurse take first?

## Option

1. Restrict fluids for the rest of the shift.
2. Assess bladder distention and obtain a bladder scan according to protocol. **✔ Correct answer**
3. Tell the client urinary retention is expected and no action is needed.
4. Insert an indwelling catheter permanently.

**Correct answer: 2**

## 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.

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