A nurse is collecting data from a client who is 2 days postoperative. The nurse auscultates bilateral breath sounds but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

A. Urinary tract infections are common at this stage. While urinary tract infections (UTIs) are a potential postoperative complication, monitoring urine output is not primarily for detecting UTIs but for ensuring adequate kidney function and overall circulatory health.

B. Decreased urine output may be a sign of shock. Decreased urine output can be a key indicator of shock, as inadequate perfusion to the kidneys during shock reduces urine production. This is a critical sign of potential hemodynamic instability and warrants immediate attention.

C. A distended bladder is uncomfortable. While a distended bladder can be uncomfortable, monitoring urine output is more about assessing kidney function and detecting issues like dehydration, shock, or kidney failure rather than simply comfort.

D. Swelling may block the ureters or urethra. Swelling may cause urinary retention, but this is less common as a primary concern postoperatively. The primary reason for monitoring urine output is to assess overall circulation and kidney function, not necessarily to monitor for obstruction.

A. Place a walker at the side of the bed. A walker may not be necessary for all patients and should only be used if prescribed by the healthcare provider.

B. Allow the patient to sit with the head of bed raised to the high Fowler’s position. This helps with postural adjustment but is not the best first step before dangling the legs.

C. Assist the patient to sit and dangle his or her legs on the side of the bed. Gradual movement from lying to sitting to standing helps prevent orthostatic hypotension, which is common after surgery.

D. Assist the patient from a supine position to a standing position. Moving too quickly can cause dizziness, falls, and syncope due to orthostatic hypotension.