Four hours after surgery, a patient's urine output has been 20 mL per hour for the last two hours. Which action should the nurse take first?
Correct answer: B. Assess the patient and notify the responsible clinician
- A. Document the output as expected after surgery
- B. Assess the patient and notify the responsible clinician
- C. Remove the urinary catheter without assessment
- D. Restrict oral fluids until the output increases
Explanation
Persistent urine output below about 30 mL per hour may indicate inadequate circulating volume or reduced renal perfusion. The nurse should assess vital signs, catheter patency and fluid status, then report the finding promptly.
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About Perioperative Nursing
Covers preoperative assessment, informed consent, surgical preparation, anaesthesia, intraoperative safety and postoperative recovery. It includes sterile technique, surgical positioning, wound and drain care, pain and nausea management, fluid balance, prevention of infection and recognition of complications such as haemorrhage, atelectasis and shock.
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