Question

The nurse in an outpatient facility is caring for a client after a laparoscopic cholecystectomy at 8:00 this morning. It is now 11:00 a.m., and the client's significant other is ready for the client to be discharged. Vital signs are stable, pain is 3/10, and the client has voided 30 ml of urine. Which nursing action is most appropriate?

a. Discharge the client; these findings are normal.
b. Delay discharge until the client's pain subsides.
c. Inform the doctor; the client's urine output is inadequate.
d. Inform the doctor; the client still complains of pain.

Answer 1

The most appropriate nursing action is to inform the doctor about the client's inadequate urine output after their laparoscopic cholecystectomy, as it suggests possible issues with kidney function or hydration levels.

Step-by-step explanation:

The appropriate nursing action in the scenario where the client had a laparoscopic cholecystectomy at 8:00 a.m., and at 11:00 a.m. has stable vital signs, pain of 3/10, and has voided only 30 ml of urine, would be to inform the doctor about the client's inadequate urine output. Typically, after surgery, adequate urine output is necessary to demonstrate that the client's kidneys are functioning well and that the client is well-hydrated. An output of 30 ml in 3 hours post-operation is considered low as the expected urine output for an adult is at least 0.5 ml/kg/hr, and for most adults, this would equate to at least 100 ml/hr.

The client's complaint of pain, while important, is not as immediately concerning as the low urine output since their pain level is manageable at 3/10.