A postoperative client develops urinary retention and voids in small amounts every 15-30 minutes. Which intervention should the nurse implement first?

Postoperative urinary retention is a common complication caused by anesthesia effects, decreased bladder tone, and impaired sensation of bladder fullness. It can lead to bladder overdistention, discomfort, and potential kidney complications if not addressed promptly. Frequent voiding in small amounts suggests incomplete bladder emptying and possible retention. Nursing priorities focus on relieving bladder distention and restoring normal urinary elimination. Rationale: A. Obtaining a urine culture and sensitivity is not the priority because there is no indication of infection such as fever, dysuria, or cloudy urine. The client’s symptoms are more consistent with mechanical retention rather than infection. Diagnostic testing can be considered later if signs of urinary tract infection develop. B. Administering bethanechol orally is not the first intervention because medication takes time to act and is not appropriate for immediate relief of acute urinary retention. Additionally, pharmacologic therapy is usually considered after confirming retention and attempting noninvasive measures. Immediate decompression of the bladder is the priority. C. Notifying the health care provider is important but should follow immediate nursing interventions aimed at relieving the client’s discomfort and preventing complications. Acute urinary retention is within nursing scope to address promptly, especially when symptoms are evident. Delaying intervention could worsen bladder distention and increase risk of injury. D. Inserting an indwelling foley catheter is the priority because it provides immediate relief of bladder distention and allows accurate measurement of urinary output. Urinary retention can lead to overstretching of the bladder muscle, which may impair future function if not promptly relieved. Catheterization restores normal drainage and prevents complications such as hydronephrosis or infection.