Question

1. the nurse is caring for a postoperative client who has not voided for 7 hours after return to the post - surgical unit. which of the following actions should the nurse take first? a. assess for bladder distension b. insert a straight catheter as indicated on the prn orders c. assist the client to ambulate to the bathroom d. notify the surgeon

Explanation:

In post - operative care, the first step when a client has not voided for a significant time (7 hours in this case) is to assess for bladder distension. This helps determine if there is an actual problem with urinary retention before taking more invasive or drastic measures like inserting a catheter or notifying the surgeon. Assisting the client to ambulate to the bathroom is not the first - step as there is a concern about urinary retention.

Answer:

A. Assess for bladder distension