The nurse is caring for a client following rectal surgery who voids about 50 mL of urine every 30-60 minutes. Which of the following nursing actions is best?
A)Use a bladder scan device to check the postvoiding residual.
B)Monitor the client's intake and output over the next few hours.
C)Have the client take small amounts of fluid frequently throughout the day.
D)Reassure the client that this is normal after rectal surgery because of anesthesia.

Question

Quizplus · Accepted Answer

A bladder scan device can be used to check for residual urine after the client voids. Because the client's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the client drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiological problem, not just reassure the client. The client may develop reflux into the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the problem for several hours.

The Nurse Is Caring for a Client Following Rectal Surgery