A client with a removed catheter reports fullness. Which action is the correct first nursing assessment?

A client with a removed catheter reports fullness. Which action is the correct first nursing assessment?

• A. Reinsert catheter
• B. Notify physician
• C. Increase fluids
• D. Perform a bladder scan 5 to 15 minutes after voiding

Answer: (D)

Facing fullness after removing a catheter suggests the bladder may not be emptying properly, so the first step is to assess the bladder’s status with a bladder scan to measure post-void residual. This noninvasive test quickly provides objective data on how much urine remains, guiding what to do next. If the scan shows significant residual, you would address it per protocol, which might include reinserting the catheter or informing the physician. Simply increasing fluids won’t determine whether retention is present and could worsen the situation, and acting without assessment or awaiting a call to the physician isn’t as effective as getting the actual measurement first. Performing a bladder scan after voiding gives a clear residual volume to guide appropriate management.

Facing fullness after removing a catheter suggests the bladder may not be emptying properly, so the first step is to assess the bladder’s status with a bladder scan to measure post-void residual. This noninvasive test quickly provides objective data on how much urine remains, guiding what to do next. If the scan shows significant residual, you would address it per protocol, which might include reinserting the catheter or informing the physician. Simply increasing fluids won’t determine whether retention is present and could worsen the situation, and acting without assessment or awaiting a call to the physician isn’t as effective as getting the actual measurement first. Performing a bladder scan after voiding gives a clear residual volume to guide appropriate management.