Practice Question
Patient Data .
Answer Choices:
Rationale:
Conditions
Urinary retention
💎The client is 3 hours post–catheter removal, unable to void, and has a palpable, egg-shaped suprapubic mass—hallmark findings of postoperative urinary retention (POUR).
💎Recent anesthesia/analgesia, surgical pain, and sympathetic stimulation transiently inhibit detrusor contraction and sphincter relaxation, predisposing to retention.
💎Stable vital signs, clean/dry dressing, and no hematuria/fever argue against hemorrhage or UTI as the primary problem.
💎A low pain score (3/10) and orders for “Up ad lib” support noninvasive attempts to void first.
💎Early recognition and conservative measures reduce risk of overdistention, reflux to ureters, infection, and the need for catheterization.
Actions
Assist the client to the commode
💎Voiding is more successful in the upright, seated position, which uses gravity and improves pelvic-floor relaxation compared with a bedpan.
💎The commode also allows privacy and natural toileting cues (e.g., running water), decreasing functional retention.
💎This action aligns with the provider’s order “Up ad lib”, promoting early mobility and comfort after abdominal surgery.
💎Provide safety support (gait belt, assistance) to prevent orthostasis or falls during first ambulation.
💎 If unsuccessful, this step documents a reasonable noninvasive attempt before escalation (e.g., bladder scan/straight cath per protocol).
Provide the client a warm drink
💎Warm oral fluids (water or decaf tea) can stimulate the parasympathetic micturition reflex and help the detrusor muscle contract.
💎The order to “Advance diet as tolerated” permits a warm drink, supporting both hydration and voiding attempts.
💎Avoid caffeinated beverages early because they may irritate the bladder and can worsen urgency without effective emptying.
💎Encouraging small, frequent sips prevents nausea in the immediate postoperative period.
💎Improved hydration increases urine production, providing the physiologic drive to void.
Parameters
Bladder distention
💎Ongoing assessment of suprapubic fullness/tenderness (and bladder scan if available) confirms whether the bladder is emptying.
💎Decreasing distention after interventions indicates progress; persistent fullness suggests need to escalate (e.g., straight cath per facility threshold, often ~400–600 mL).
💎Watch for overflow incontinence, rising discomfort, or worsening pain, which signal overdistention.
💎Document size/scan volumes and patient symptoms to guide the timing of further actions.
💎Timely relief prevents detrusor damage and reduces risk of UTI.
Intake & Output (I&O)
💎 Accurate I&O differentiates low intake/low output from adequate intake with poor emptying (true retention).
💎 Rising intake with absent or minimal output supports retained urine and the need for intervention.
💎 Tracking I&O also safeguards renal perfusion and detects early postoperative oliguria.
💎 Trending outputs after interventions (commode/warm fluids) shows response and helps decide if catheterization is needed.
💎 Precise I&O documentation is essential for clinical decision-making and provider communication.
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This question is from HESI-PN fundamentals with NGN which contains 59 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN HESI Exams
- Domain: Fundamentals of Nursing
- Answer Choices: 0