A client has not voided eight hours after surgery and says to the nurse, “I don’t think I can urinate.” What should be the first action for the nurse?
Assess the client’s bladder.
Administer pain medication.
Increase the client’s fluid intake.
Inform the surgeon of the client’s status.
The Correct Answer is A
The nurse should first assess the client’s bladder for distention by palpating the lower abdomen between the symphysis pubis and the umbilicus.
This can indicate urinary retention, which is a common postoperative complication. The nurse should also measure the bladder volume using a bladder scanner if available.
Choice B. Inform the surgeon that the client’s status is wrong because the nurse should first assess the client before notifying the surgeon.
The surgeon may order interventions based on the assessment findings.
Choice C. Increasing the client’s fluid intake is wrong because increasing fluid intake may worsen bladder distention and discomfort.
The nurse should encourage fluid intake only after ensuring adequate urinary output.
Choice D. Administering pain medication is wrong because pain medication may not be indicated for urinary retention.
Pain medication may also cause urinary retention by relaxing the bladder muscles and impairing the micturition reflex.
Normal urine output is about 30 mL per hour or 240 mL in eight hours.
The nurse should monitor the client’s intake and output and report any signs of urinary retention to the surgeon.
Urinary retention can lead to infection, bladder damage, and renal impairment if not treated promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“Have you had thoughts about killing yourself?” This is the best response because it directly assesses the client’s suicidal risk and shows empathy and concern.
The other choices are wrong because:
Choice B. “What can’t you go on anymore?” This is a vague and open-ended question that does not address the client’s immediate safety or emotional state.
Choice C. “Don’t think like that.
It’s not true!” This is a dismissive and invalidating response that does not acknowledge the client’s feelings or offer support.
Choice D. “Have you talked to your doctor about these feelings?” This is a deferring and avoiding response that does not explore the client’s situation or provide any intervention.
Correct Answer is B
Explanation
I should always have my breakfast ready to eat before injecting my morning insulin. This statement confirms that the client understands the importance of matching insulin administration with food intake to prevent hypoglycemia.
Choice A is wrong because hemoglobin A1C should be checked every 3 months, not monthly, to monitor long-term glycemic control.
Choice C is wrong because eating early and taking extra insulin later can cause fluctuations in blood glucose levels and increase the risk of complications.
Choice D is wrong because on sick days, the client should check blood sugar more
often and eat small amounts of carbohydrates to prevent hyperglycemia and ketoacidosis.
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