Question

The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient's urine output has been less than 20 mL/hour for the past 2 hours. It is 0200 in the morning. The patient's blood pressure is 100/60 mm Hg, and the pulse is 110 beats per minute. Previously, the pulse was 90 beats per minute with a blood pressure of 120/80 mm Hg. The nurse should:

a. contact the provider and expect an order for a normal saline bolus.
b. wait until 0900 when the provider makes rounds to report the assessment findings.
c. continue to evaluate urine output for 2 more hours.
d. ignore the urine output, as this is most likely postrenal in origin.

Answer 1

A nurse observing a postoperative patient with oliguria and signs of decreasing blood pressure and increasing heart rate should contact the provider immediately and expect a possible order for a saline bolus to address potential hypovolemia or shock.

Step-by-step explanation:

The patient with urine output less than 20 mL/hour for the past 2 hours after major abdominal surgery is demonstrating signs of oliguria, which can be associated with acute kidney injury or severe dehydration. Considering the patient's declining blood pressure and increasing pulse, the nurse should contact the provider to alert them to the signs of potential hypovolemia or shock, and expect an order for a normal saline bolus to restore fluid balance. Since the nurse observed a decrease from a previous blood pressure of 120/80 mm Hg and a pulse of 90 beats per minute to the current 100/60 mm Hg and a pulse of 110 beats per minute, these changes suggest a state of compensatory shock where the body is attempting to maintain perfusion to vital organs. It's imperative not to delay intervention during such critical changes in a postoperative patient.