Four hours after surgery, a client's urine output has been 20 mL/hr for 2 hours. The client has no catheter and reports lower abdominal discomfort. What should the nurse do first?

A. Assess the bladder with a bladder scanner
B. Insert an indwelling catheter
C. Notify the provider of possible kidney failure
D. Increase the IV fluid rate

Show answer and rationale

Correct answer: A

Lower abdominal discomfort with low output after surgery suggests urinary retention. A bladder scan is a quick, noninvasive assessment that guides next steps such as straight catheterization per protocol.

Source: Lewis's Medical-Surgical Nursing, 13th ed. (urinary retention)

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Four hours after surgery, a client's urine output has been 20 mL/hr for 2 hours. The client has no catheter and reports lower abdominal discomfort. What should the nurse do first?

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