The nurse is caring for an older adult who is recovering from hip replacement surgery. The client shares with the nurse that he has been using the urinal "a lot but I feel like my bladder isn't emp-ty."

Question

Which of the following statements by the nurse shows the best understanding of the appropriate initial intervention for this particular client?
1. "I'll call your primary care provider and let her know you are having this prob-lem."
2. "I have the ancillary personnel measure your output, so please don't empty your urinal yourself."
3. "I'm going to ask that you please use your call bell and notify me or the ancillary staff each time you void."
4. "I suggest that we try limiting the amount of fluids you are drinking for a few hours and see if that helps."

Answer 1

ANS: 3
With retention the client may void small amounts of urine 2 or 3 times an hour with no real relief of discomfort or may continually dribble urine. Be aware of the volume and frequency of voiding to assess this condition in the client. The alert, oriented client can be asked to notify the nurse each time micturition occurs. The notification of the primary care provider is not the initial inter-vention. Although measuring the urine output is not inappropriate, it is not specific to this client's complaint. Restricting fluids is neither appropriate nor likely to affect the problem.