A client has not voided for 8 hours following the removal of an indwelling catheter.

The nurse has clinically reasoned that the client may be experiencing urinary retention.

Which of the following should be the nurse's first action?

Choice A rationale

Routine catheterization solely for the convenience of staff or family is inappropriate, as it violates established infection prevention guidelines and client rights. Indwelling urinary catheters are a major source of healthcare-associated urinary tract infections (UTIs) because they introduce pathogens directly into the bladder, which outweighs any convenience factor. Catheters are only justified by specific medical necessity.

Choice B rationale

Obtaining a routine urine specimen for urinalysis or culture does not typically require the insertion of an indwelling or straight catheter, as a clean-catch midstream sample is usually sufficient and non-invasive. Catheterization is only indicated for specimens if the client cannot voluntarily void or if an uncontaminated sample is urgently needed and other methods have failed.

Choice C rationale

Strict intake and output (I O) monitoring is a valid indication for an indwelling catheter, especially in critically ill or unstable clients where hourly urine volume is crucial for assessing fluid balance, renal perfusion, and response to therapy. Accurate, continuous measurement is often impossible without a catheter in these complex situations.

Choice D rationale

Performing routine daily care, such as bathing or linen changes, is not a justifiable medical reason for inserting a urinary catheter. This non-therapeutic use unnecessarily exposes the client to the significant risks of catheter-associated urinary tract infection (CAUTI), mechanical trauma, and discomfort, and is strongly discouraged by best practice guidelines.

Choice E rationale

The presence of an unhealing open perineal or sacral wound, particularly one contaminated by urine or feces, is a valid indication for a temporary indwelling catheter. The catheter helps keep the area dry and free from continuous contamination, which is essential for wound healing and preventing further skin breakdown and infection.

Choice F rationale

Urinary retention, defined as the inability to empty the bladder, is a primary and necessary indication for catheterization (either straight or indwelling). The retention causes bladder distension and potentially serious complications like hydronephrosis or renal damage, requiring prompt catheter insertion for immediate therapeutic decompression and relief.

Choice A rationale

Seeing "white halos around objects" is a classic visual disturbance, specifically termed chromatopsia or xanthopsia (yellow-green halos), which is a key sign of digoxin toxicity. Digoxin, a cardiac glycoside, affects visual pathways. Other early signs include gastrointestinal upset, fatigue, and bradycardia, indicating drug accumulation above the therapeutic range of 0.5 to 2.0 nanograms per milliliter.

Choice B rationale

A red, beefy tongue, or glossitis, is primarily a sign of a severe deficiency in B vitamins, such as B12, folate, or niacin, which is associated with conditions like pernicious anemia. This is not a characteristic sign or symptom of toxicity resulting from the cardiac glycoside medication digoxin, which exerts its effects on the heart muscle and central nervous system.

Choice C rationale

Digoxin toxicity commonly manifests with early gastrointestinal symptoms, but these typically include nausea, vomiting, anorexia, and sometimes diarrhea, which reflect central nervous system stimulation. Constipation, which is the decreased frequency of bowel movements, is not a common or expected side effect or sign of drug toxicity.

Choice D rationale

Weight gain, especially rapid gain, can indicate fluid retention due to worsening heart failure, a condition digoxin is used to treat. While toxicity can cause anorexia (loss of appetite), it does not typically cause weight gain. Therefore, weight gain may suggest therapeutic failure or worsening disease, not necessarily digoxin toxicity itself. —.