Question

Which of the following nursing interventions would be the most appropriate for a patient who, four hours post urinary catheter removal, expresses the need to void but is unable to?

A) Encourage increased fluid intake to stimulate urination.
B) Perform a bladder scan to assess urine volume.
C) Assist the patient in assuming different positions to aid voiding.
D) Reinsert the urinary catheter to relieve urinary retention.

Answer 1

Performing a bladder scan to assess urine volume is the most appropriate nursing intervention for a patient unable to void four hours post urinary catheter removal.

Step-by-step explanation:

The most appropriate nursing intervention for a patient who is unable to void four hours post urinary catheter removal would be to B) Perform a bladder scan to assess urine volume.

A bladder scan uses ultrasound technology to measure the amount of urine in the bladder. This would help determine if the patient is experiencing urinary retention, which is preventing them from being able to void. Performing a bladder scan allows the healthcare provider to assess the situation and make an informed decision about further interventions.

Encouraging increased fluid intake (A) may help stimulate urination in some cases, but it may not be effective if there is a physical obstruction or urinary retention. Assisting the patient in assuming different positions (C) may also aid voiding, but a bladder scan would be a more appropriate initial intervention. Reinserting the urinary catheter (D) should only be done if conservative measures do not resolve the issue.