A patient with multiple sclerosis is receiving baclofen.
The nurse determines that the drug is effective when it produces which outcome?

Choice A rationale

Inserting an indwelling urinary catheter prematurely without assessing for bladder distension or attempting other less invasive interventions is not the first step. Catheterization carries risks like infection and trauma. A bladder scan provides objective data to guide further interventions.

Choice B rationale

Positioning the patient on their left side is not a primary intervention for urinary retention after catheter removal. While position can sometimes aid voiding, it is not a direct solution for a patient who has not voided for 8 hours and does not address the underlying issue of bladder fullness.

Choice C rationale

Performing a bladder scan is the most appropriate next nursing action. A bladder scan non-invasively measures the volume of urine in the bladder. If the bladder volume is significant (e.g., >200-400 mL, normal post-void residual is <50-100 mL), it indicates urinary retention, guiding further interventions.

Choice D rationale

Instructing the patient to drink fluids without assessing for bladder distension can exacerbate the problem if the patient is already experiencing retention. Increasing fluid intake without adequate outflow can lead to overdistension of the bladder, causing further discomfort and potential bladder damage.

Choice A rationale

While increased fluid intake helps flush bacteria from the urinary tract, encouraging 8 ounces of water every hour could lead to excessive fluid intake (polydipsia) and electrolyte imbalances, specifically hyponatremia, which is not a normal physiological state. A more balanced hydration strategy is generally recommended to prevent urinary tract infections.

Choice B rationale

Proper perineal hygiene, specifically wiping from front to back, is crucial for female patients because it prevents the transfer of fecal bacteria (e.g., Escherichia coli) from the anal region to the urethral opening. The female urethra is short and in close proximity to the anus, making it highly susceptible to ascending bacterial infections without this practice.

Choice C rationale

Using bath powder can introduce foreign particles and potentially irritating substances into the sensitive perineal area, which may disrupt the natural microbial balance and increase the risk of irritation or infection, rather than preventing urinary tract infections. Moisture absorption is better managed through breathable undergarments and good hygiene.

Choice D rationale

Advising patients to hold urine for extended periods can lead to urinary stasis, where urine remains in the bladder for too long, allowing bacteria more time to multiply and ascend the urinary tract. Regular and complete bladder emptying is essential for flushing out potential pathogens and reducing the risk of urinary tract infections.