It is 2000 hours, and the nurse notes that an adult male who returned from the PACU at 1400 hours has not voided. The client has an out of bed order, but has not been up yet. The best action for the nurse to take is:
a, encourage the client the on his left side in bed and attempt to void into a urinal
b. straight-catheterize the client
c. assist the client to stand at the side of his bed and attempt to void into a urinal
d. obtain an order for a Foley catheter
The correct answer and explanation is:
The correct answer is c. assist the client to stand at the side of his bed and attempt to void into a urinal.
Explanation:
Post-operative urinary retention is a common complication after surgery, especially following anesthesia. Anesthesia can affect the bladder’s ability to contract, and the client’s urge to urinate may be delayed. However, after 6 hours, the nurse should begin to evaluate whether the client can void independently.
In this case, the client has been out of the PACU for 6 hours, and there has been no voiding yet. The fact that the client has an out-of-bed order suggests that ambulation is encouraged to stimulate normal bladder function. Encouraging the client to stand and attempt to void can facilitate the natural voiding process by allowing gravity to assist. In addition, standing helps promote normal bladder function by activating the pelvic muscles and reflexes necessary for urination.
Encouraging the client to void into a urinal while standing can also provide privacy, which may help reduce any anxiety or discomfort associated with urination, increasing the likelihood of success.
Option a (encourage the client on his left side in bed and attempt to void into a urinal) is less effective because lying on one side in bed can sometimes limit the client’s ability to fully engage the muscles required for urination. In this position, the client may not be able to initiate voiding as easily.
Option b (straight-catheterize the client) should not be the first action unless the client is unable to void after attempts, as catheterization increases the risk of infection and trauma. It is a more invasive intervention, typically used when non-invasive options fail.
Option d (obtain an order for a Foley catheter) is also an inappropriate first step. A Foley catheter is usually only indicated when the client cannot void after multiple attempts, and there is a risk of bladder overdistention or urinary retention. A Foley catheter should not be inserted as the first intervention unless clinically necessary.