A postoperative patient has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?
a. Perform a bladder scan.
b. Encourage increased oral fluid intake.
c. Assist the patient to ambulate to the bathroom.
d. Insert a straight catheter as indicated on the PRN order.
ANS: A
The initial action should be to assess the bladder for distention. If the bladder is distended, providing the patient with privacy (by walking with them to the bathroom) will be helpful. Because of the risk for urinary tract infection, catheterization should only be done after other measures have been tried without success. There is no indication to notify the surgeon about this common postoperative problem unless all measures to empty the bladder are unsuccessful.
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