# Situation: A 65-year-old man weighing 68 kg has an open small-bowel resection under general anesthesia. He returns to the surgical ward with a nasogastric tube to low suction and a wound drain. No urinary catheter was placed, and he is kept nothing by mouth (NPO). Eight hours after he returned to the ward he has not voided. He reports lower abdominal discomfort, and a bladder scan shows 650 mL. Standing at the bedside and running water have not helped. What should the nurse do next?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629873  
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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 65-year-old man weighing 68 kg has an open small-bowel resection under general anesthesia. He returns to the surgical ward with a nasogastric tube to low suction and a wound drain. No urinary catheter was placed, and he is kept nothing by mouth (NPO).

Eight hours after he returned to the ward he has not voided. He reports lower abdominal discomfort, and a bladder scan shows 650 mL. Standing at the bedside and running water have not helped. What should the nurse do next?

## 보기

1. Drain the bladder with a catheter as ordered **✔ 정답**
2. Increase the intravenous rate and recheck in 4 hours
3. Restrict intravenous fluids until he can void on his own
4. Apply a warm pack to the lower abdomen and wait 2 hours

**정답: 1**

## 해설

Failure to void within 6–8 hours with a distended bladder confirmed by scan is urinary retention. Once simple measures fail, the bladder is drained by catheterization as ordered to relieve discomfort and prevent overdistension injury.

## 심화 해설

Why the bladder is at risk after surgery

This patient has several factors that make postoperative urinary retention likely. General anesthesia temporarily interrupts the micturition reflex, and the small-bowel resection itself, along with postoperative pain and immobility, further suppresses normal voiding. Because he is NPO and has a nasogastric tube on suction, intravenous fluids are the main source of urine output, so the bladder continues to fill even though he has not voided.

Eight hours after surgery, a bladder scan showing 650 mL with lower abdominal discomfort indicates acute urinary retention, not simply low urine output. Normal bladder capacity is roughly 400–600 mL, and volumes above this range place the detrusor muscle under excessive stretch.

Why catheterization is the next step

Simple nursing measures such as standing at the bedside and running water have already failed. When noninvasive voiding prompts are unsuccessful and the bladder is distended, the priority is to drain the bladder with a catheter as ordered to relieve discomfort and prevent overdistension injury. Prolonged overdistension can damage the detrusor muscle and delay return of normal bladder function.

The bladder scan value of 650 mL is above the commonly used threshold for catheterization. One of the referenced sources notes that catheterization is recommended when bladder volume exceeds 600 mL [4]. A more recent algorithm for adult inpatients also emphasizes that bladder scanning should guide the decision to catheterize when retention is confirmed [1].

Why the other options are not appropriate

Increasing the intravenous rate would worsen bladder filling and increase discomfort without addressing the mechanical problem of retention. Restricting intravenous fluids would not solve the immediate problem of a bladder that is already overdistended, and it could contribute to hypovolemia in a postoperative patient. Applying a warm pack and waiting another 2 hours delays needed intervention and prolongs detrusor stretch.

| Intervention | Rationale | Problem |
| --- | --- | --- |
| Catheterization | Drains distended bladder, relieves discomfort, prevents overdistension injury | Correct next step |
| Increase IV rate | Assumes low urine output is the issue | Worsens bladder distension |
| Restrict IV fluids | Attempts to reduce future urine production | Does not treat existing retention; risks hypovolemia |
| Warm pack and wait | Noninvasive comfort measure | Already failed simple measures; delays needed drainage |

Key point! A bladder scan is the objective tool that confirms retention. When the volume is high and simple voiding measures have failed, catheterization is the standard next action.

Watch out! Do not assume that no urine output means the kidneys are not producing urine. In postoperative retention, urine is being produced but is trapped in the bladder.

Clinical reasoning for the nursing licensure exam

Postoperative urinary retention is common, with reported incidence ranging widely from 5% to 70% depending on surgery type, anesthesia, and patient factors . Older age and certain surgical procedures increase risk [4]. The nurse should recognize that a distended bladder confirmed by ultrasound or bladder scan is a clear indication for catheterization when conservative measures fail [1][4].

In this patient, the combination of general anesthesia, abdominal surgery, NPO status, and a bladder volume of 650 mL at 8 hours postoperatively supports the diagnosis of acute urinary retention. The correct nursing action is to drain the bladder with a catheter as ordered, because this directly relieves the obstruction, reduces discomfort, and protects the detrusor muscle from further stretch injury.References (research sources)

- [1]Urinary Retention Evaluation and Catheterization Algorithm for Adult Inpatients.Research articleChrouser K, Fowler KE, Mann JD, Quinn M, Ameling J, Hendren S (2024) · DOI: 10.1001/jamanetworkopen.2024.22281

- [4]Postoperative urinary retention.Research articleDarrah DM, Griebling TL, Silverstein JH (2009) · DOI: 10.1016/j.anclin.2009.07.010

## 임상 시나리오

Postoperative Urinary Retention ManagementBladder scan-guided catheterization thresholds
After general anesthesia and abdominal surgery, urinary retention is common due to interrupted micturition reflex, pain, and immobility. Assess voiding within 6–8 hours postoperatively.

A bladder scan volume above 600 mL after failed voiding attempts indicates the need for catheterization. Normal bladder capacity is approximately 400–600 mL.

Try noninvasive measures first: standing, running water, privacy, and warmth. If these fail and the bladder remains distended, proceed to catheterization as ordered.

CautionDelaying catheterization in confirmed retention risks detrusor overdistension injury, which can prolong bladder dysfunction. Do not increase IV fluids or restrict fluids as primary management.

## 핵심 개념

- **urinary retention** — Inability to void despite a full bladder; postoperative causes include anesthesia, pain, immobility, and fluid shifts.
- **bladder scan** — Noninvasive ultrasound measurement of bladder volume; >600 mL after voiding attempts indicates need for catheterization.
- **detrusor overdistension** — Excessive stretching of bladder muscle from retained urine, which can impair contractility and delay return of normal voiding.
- **catheterization** — Insertion of a urinary catheter to drain the bladder; indicated when noninvasive voiding measures fail and bladder is distended.
- **NPO** — Nothing by mouth; postoperative patients rely on IV fluids for hydration, which continues to fill the bladder.

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