The nurse is caring for a patient who reports an urgent need to urinate but is unable to pass more than a few drops of urine on the toilet. Which is the priority assessment to be performed by the nurse?
a. Bladder scan to determine the amount of urine in the bladder
b. Auscultation to assess circulation through the right and left renal arteries
c. Bimanual palpation to assess for possible enlargement of the kidneys
d. Calculate the patient's intake and output to check for fluid volume deficit
ANS: A
The patient with suspected urinary retention should have a bladder scan performed to determine the amount of urine in the bladder. If a significant amount of urine is found in the bladder, the physician may be notified to obtain an order for straight catheterization.
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