NCLEX · Reduction of Risk Potential

A post-operative client is 6 hours after abdominal surgery and has not urinated. What is the nurse's FIRST action?

Correct answer

Assess for bladder distension by palpating the suprapubic area and assessing for patient's urge to void; check the IV fluid intake and output record; ambulate the patient if able — urinary retention after abdominal surgery is common from anesthesia effects, opioid medications, and positional factors

  1. A Insert a urinary catheter immediately
  2. B Assess for bladder distension by palpating the suprapubic area and assessing for patient's urge to void; check the IV fluid intake and output record; ambulate the patient if able — urinary retention after abdominal surgery is common from anesthesia effects, opioid medications, and positional factors
  3. C Restrict fluids until the patient voids
  4. D Document and wait 2 more hours before taking action

Why this is the answer

POST-OPERATIVE URINARY RETENTION ASSESSMENT: NORMAL: Most patients void within 6-8 hours after surgery; ASSESSMENT FIRST: Before inserting a catheter (invasive procedure), assess: palpate suprapubic area for distension and firmness; ask if patient feels urge to void; review total fluid intake (IV + oral) since surgery; BLADDER SCANNER: If available, perform bladder scan to quantify volume (>300-400 mL with inability to void = retention); CONSERVATIVE INTERVENTIONS: Offer bedpan or urinal in a private, comfortable position; run water audibly; apply warm compress to suprapubic area; ambulate to the bathroom if safe and ordered; CATHETERIZATION THRESHOLD: Typically if conservative measures fail AND bladder volume >500 mL OR patient has significant discomfort; COMMON CAUSES: Anesthesia (bladder relaxation); opioid medications (urethral sphincter tone increased); lying flat (difficult to void for many people); anxiety. PN SCOPE: Assess, implement conservative measures, report to RN for catheterisation orders.
Source: NCLEX-PN Test Plan: Physiological — Post-op Urinary Retention Assessment