A postoperative patient has not voided for 8 hours after return ...

[burchfield96]

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.

Question 2

The nurse is caring for a patient the first postoperative day following a laparotomy for a small bowel obstruction. The nurse notices new bright-red drainage about 5 cm in diameter on the dressing. Which action should the nurse take first?
 
  a. Reinforce the dressing.
  b. Apply an abdominal binder.
  c. Take the patient's vital signs.
  d. Recheck the dressing in 1 hour for increased drainage.

[heinisk01]

Answer to Question 1

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.

Answer to Question 2

ANS: C
New bright-red drainage may indicate hemorrhage, and the nurse should initially assess the patient's vital signs for tachycardia and hypotension. The surgeon should then be notified of the drainage and the vital signs. The dressing may be changed or reinforced, based on the surgeon's orders or institutional policy. The nurse should not wait an hour to recheck the dressing.