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    Ati lpn sp26 medical surgical proctored exam

    A nurse removes a client's Foley catheter and documents that the client urinates 4 hr later. Which of the following elements of postoperative care is the nurse performing?

    Explanation & Rationale

    A. Assisting with early ambulation: Early ambulation involves helping the client walk shortly after surgery to prevent venous thromboembolism and promote gastrointestinal motility. While moving can stimulate bladder activity, documenting a specific voiding event is a direct assessment of renal and bladder output. This action focuses on mobility rather than the physiological excretion of urine. B. Managing postoperative pain: Pain management involves assessing comfort levels and administering analgesics or non-pharmacological interventions to facilitate recovery. Monitoring for the first void after catheter removal is a safety measure to detect urinary retention rather than an analgesic intervention. Successful voiding indicates the absence of anesthesia-induced bladder atony or urethral trauma. C. Monitoring urinary function: Removing an indwelling catheter necessitates close observation to ensure the client regains the ability to void spontaneously and effectively. Documenting the timing and volume of the first void confirms that the detrusor muscle and urethral sphincter are functioning correctly post-anesthesia. This is a critical component of assessing renal and urological recovery. D. Providing surgical site or wound care: Wound care focuses on inspecting incisions for signs of infection, dehiscence, or hematoma and performing sterile dressing changes. Urinary output is an internal physiological process and does not directly relate to the integrity of cutaneous surgical margins. Tracking micturition is a functional assessment rather than a local tissue intervention.

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