The nurse is caring for a male client with a history of benign prostatic hyperplasia (BPH) who reports being unable to void any urine for the last 8 hours.
Which of the following actions should the nurse take first?

Choice A rationale

Stones lodged in the ureter cause severe, colicky pain due to intense peristaltic waves attempting to dislodge the obstruction. The pain often radiates down the thigh and groin as the ureter's path follows these areas. Additionally, urinary retention or frequent urges with minimal voiding occurs due to irritation and partial blockage, confirming ureteral stone involvement.

Choice B rationale

While some stones may pass spontaneously, timing varies widely depending on size, location, and hydration levels. Pain and obstruction may persist longer than a few hours, making this statement misleading without further assessment.

Choice C rationale

Bladder stones may cause lower abdominal pain, frequency, and hematuria but do not typically involve radiating pain to the groin or thigh. The described symptoms strongly suggest ureteral obstruction rather than bladder involvement.

Choice D rationale

While procedural removal is an option for large or immovable stones, initial approaches often include pain control, hydration, and medical expulsive therapy. Surgical intervention is not the first-line explanation unless conservative management fails.

Choice A rationale

Teaching preventive measures, like proper hydration and hygiene, is integral for long-term UTI management but not the immediate clinical priority. Effective prevention helps reduce recurrence rates but does not address acute infection or associated complications during the current episode.

Choice B rationale

Preventing progression to complications takes priority in lower UTIs. This includes early and appropriate antibiotic therapy to inhibit bacterial proliferation and monitoring for symptoms suggestive of an ascending infection. Left untreated, lower UTIs can progress to pyelonephritis, a serious condition that increases morbidity.

Choice C rationale

Educating about treatment ensures compliance with the prescribed antibiotics and symptom management strategies. While necessary, client education is more aligned with secondary interventions after addressing the urgent need to prevent complications from the infection itself.

Choice D rationale

Pain management is important to alleviate discomfort and improve the client’s quality of life. However, addressing pain without resolving the underlying infection risks further complications. Thus, pain control, while valuable, is not the critical first-line intervention for preventing clinical deterioration. .