The nurse evaluates a client after removing their indwelling urinary catheter. For each assessment finding, click to specify whether the finding is expected or unexpected.

Rationale:

• The client is able to void 2 hours after catheter removal – Expected
  After removal of an indwelling urinary catheter, the bladder should regain function and the client is expected to void within 6–8 hours. Voiding within 2 hours indicates normal bladder tone, intact detrusor muscle activity, and appropriate neurologic control of urination. This is a normal and reassuring finding.
• The client is experiencing mild burning with first voided urine – Expected
  Mild dysuria with the first void is common due to temporary urethral irritation from catheter insertion and removal. The urethral mucosa may be slightly inflamed. This discomfort should be mild and short-lived (typically resolving within 24 hours). Persistent or worsening pain would require evaluation.
• The client has a fever, dysuria, and flank pain – Unexpected
  These findings suggest a urinary tract infection (UTI). Fever and dysuria indicate infection, and flank pain raises concern for upper urinary tract involvement such as pyelonephritis. This is not an expected finding after routine catheter removal and requires prompt provider notification.
• The client is unable to void 8 hours after catheter removal – Unexpected
  Failure to void within 6–8 hours may indicate urinary retention due to bladder atony, urethral swelling, obstruction, or neurologic dysfunction. Prolonged retention can cause bladder overdistention and renal complications. The nurse should perform a bladder scan and notify the provider as indicated.
• The client has lower abdominal pain, hematuria, and change in mental status – Unexpected
  Lower abdominal pain may indicate bladder distention from urinary retention. Hematuria suggests trauma to the urinary tract or infection. A change in mental status, particularly in older adults, may be an early sign of a UTI or sepsis. These findings are abnormal and require immediate assessment and intervention.

Rationale:
A. A flow rate of 4 liters per minute is within the safe range for a nasal cannula but is not the maximum recommended rate. While some clients may require this flow, higher flow rates are possible and safe under certain conditions.

B. A flow rate of 6 liters per minute is the maximum flow rate typically recommended for a standard nasal cannula. Exceeding this rate can cause drying of the nasal mucosa, discomfort, and reduced effectiveness of oxygen delivery. Flow rates above 6 liters per minute generally require the use of a different delivery device, such as a simple face mask or high-flow oxygen system, to maintain safety and adequate oxygenation.

C. A flow rate of 8 liters per minute is too high for a standard nasal cannula and can cause nasal irritation, drying, and discomfort. It may also be less effective because the client may inhale room air that dilutes the oxygen.

D. A flow rate of 2 liters per minute is safe and commonly used for clients needing low-level supplemental oxygen, but it is not the maximum allowable flow rate for a nasal cannula.