Following rectal surgery, a patient voids about 50 mL of urine every 30 to 60 minutes for the first 4 hours. Which nursing action is most appropriate?
a. Monitor the patient's intake and output over night.
b. Have the patient drink small amounts of fluid frequently.
c. Use an ultrasound scanner to check the postvoiding residual volume.
d. Reassure the patient that this is normal after rectal surgery because of anesthesia.
ANS: C
An ultrasound scanner can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiologic problem, not just reassure the patient. The patient may develop reflux into the renal pelvis and discomfort from a full bladder if the nurse waits to address the problem for several hours.
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