A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the 2nd postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1,000 mL intake. Which of the following interventions is a priority for the nurse at this time?
1. Apply a condom catheter.
2. Assess for bladder distention.
3. Obtain a urine specimen for culture.
4. Teach the client Kegel exercises.
The imbalance between the client’s intake and output indicates that the client may be retaining urine since the removal of his Foley catheter. The nurse’s first action is to validate this assumption by assessing for bladder distention.
Applying a condom catheter will not relieve urinary retention; condom catheters are meant to be used for incontinence. A urine specimen for a culture is obtained if a urinary infection is suspected, but this is not a priority at this point. Kegel exercises are helpful in controlling urinary dribbling but do nottreat retention.
CN: Reduction of risk potential; CL: Synthesize
小编寄语：accept what was and what is, and you’ll have more positive energy to pursue what will be.接受过去和现在的模样，才会有能量去追寻自己的未来。