A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?
Explanation & Rationale
A. Remove the catheter and palpate the client's bladder for residual distention: This is not the next appropriate action. Palpating the bladder does not address the immediate need to relieve the remaining urine or monitor for signs of overdistension. B. Allow the bladder to empty completely or up to 1,000 mL of urine: Gradual emptying is recommended to prevent bladder spasms and circulatory compromise due to rapid decompression of a distended bladder. It is safe to continue draining the urine up to 1,000 mL in a controlled manner before considering clamping the catheter temporarily if needed. C. Clamp the catheter for thirty minutes and then resume draining: Clamping after draining only 500 mL is unnecessary. The bladder should be allowed to empty up to 1,000 mL first, as gradual decompression is generally safe and therapeutic. Clamping prematurely might cause unnecessary discomfort or delay effective bladder emptying. D. Remove the catheter and replace with an indwelling catheter: Replacing the catheter is not required unless there is a clinical indication, such as repeated urinary retention or prolonged voiding difficulties. A straight catheter is appropriate for one-time use unless otherwise specified.