When a postoperative client has a urine output of 25 mL in one hour, what is the nurse's initial response?

When a postoperative client has a urine output of 25 mL in one hour, what is the nurse's initial response?

• A. Review the client’s medication list for potential causes.
• B. Check the client's overall intake and output record.
• C. Increase the client's fluid intake.
• D. Call the physician to report the finding.

Answer: (B)

Monitoring a client’s urine output is crucial in the postoperative setting, as it can indicate renal function and overall fluid status. When a client has a urine output of only 25 mL in one hour, the appropriate first action for the nurse is to check the client’s overall intake and output record. This step provides essential context regarding the patient's fluid balance and helps identify if the low output is related to inadequate fluid intake, pre-existing conditions, or surgical factors. By reviewing the intake and output record, the nurse can ascertain whether the patient has been receiving adequate fluids and whether any changes in urine output are consistent over time. This record can help determine if further action is necessary and guide subsequent interventions, such as increasing fluid intake or alerting the physician based on a more comprehensive understanding of the situation. The other choices involve steps that could be appropriate depending on the findings from the intake and output record. However, they do not address the immediate need to gather more information about the client's recent fluid status and urine output patterns. Thus, assessing the intake and output record is a critical first step to ensure the best focused care for the patient.

Monitoring a client’s urine output is crucial in the postoperative setting, as it can indicate renal function and overall fluid status. When a client has a urine output of only 25 mL in one hour, the appropriate first action for the nurse is to check the client’s overall intake and output record. This step provides essential context regarding the patient's fluid balance and helps identify if the low output is related to inadequate fluid intake, pre-existing conditions, or surgical factors.

By reviewing the intake and output record, the nurse can ascertain whether the patient has been receiving adequate fluids and whether any changes in urine output are consistent over time. This record can help determine if further action is necessary and guide subsequent interventions, such as increasing fluid intake or alerting the physician based on a more comprehensive understanding of the situation.

The other choices involve steps that could be appropriate depending on the findings from the intake and output record. However, they do not address the immediate need to gather more information about the client's recent fluid status and urine output patterns. Thus, assessing the intake and output record is a critical first step to ensure the best focused care for the patient.