Question

A nurse is caring for a client who is postoperative following abdominal surgery. 1100: Client received from PACU 1200: Client reports nausea and pain as 8 on a scale of 0 to 10. Abdominal dressing intact, no further drainage noted. Urine output 15 mL since arrival from PACU. Analgesic and antiemetic administered as prescribed. 1230: Client reports relief from nausea and pain as 4 on a scale of 0 to 10. SaO2 96%. Repositioned for comfort. Encouraged to turn, cough, and deep breathe. 1300: No additional urine output since 1200 Which of the following actions should the nurse take?

a. Plan to ambulate the client as soon as possible
b. Instruct the client to splint the abdomen with a pillow for coughing
c. Report urinary output to the provider
d. Ask the client to rate their pain on a 0 to 10 scale.
e. Apply oxygen via a face mask.

Answer 1

The nurse should report the low urinary output to the provider, as it may indicate inadequate renal perfusion or postoperative complications, such as urinary retention or acute kidney injury. Urinary output needs to be monitored closely after surgery to prevent these potential complications.

Step-by-step explanation:

The nurse's primary concern should be the client's low urinary output, which may indicate inadequate renal perfusion or the possibility of postoperative complications such as urinary retention or acute kidney injury. Therefore, the correct action to take is: c. Report urinary output to the provider

Since the urinary output hasn't increased since the previous measurement at 1200 and it's 1300, reporting this finding to the provider is crucial for timely intervention. While splinting of the abdomen with a pillow during coughing is a standard post-operative recommendation to support the abdominal muscles and reduce pain, it is not directly related to the concern of low urinary output. Checking pain levels and planning to ambulate the patient could be secondary considerations after addressing the urgent issue of urinary output. Applying oxygen is unnecessary unless SaO2 levels are low or the patient is showing signs of respiratory distress, which isn't indicated in the scenario.