The nurse is preparing to administer a soapsuds enema to an adult client with constipation. Which action should the nurse take to ensure client safety during the procedure?

Rationale:

• Intramuscular injection is correctly matched with the vastus lateralis because this large muscle is commonly used for IM injections due to its size and good blood supply.
• Intradermal injection is correctly matched with under the epidermis in the forearm because intradermal injections are administered just beneath the epidermis, typically on the inner forearm for tests such as tuberculosis screening.
• Subcutaneous injection is correctly matched with the umbilical region of the abdomen because subcutaneous injections are given into the fatty tissue beneath the dermis, and the abdomen is a common site for medications such as insulin and heparin.
• Intravenous injection is correctly matched with the antecubital vein because IV injections are administered directly into a vein, and the antecubital area is a commonly used site for venous access.

Rationale:
A. A client with a history of frequent urinary tract infections (UTIs) does have some risk for complications related to the urinary system, such as recurrent infections or bladder irritation. However, this history does not directly cause acute urinary retention. While monitoring is important, the client is not at the highest immediate risk for retention compared to others with more direct risk factors.

B. A urine output of 32 mL in the last hour is considered low (oliguria), and while it warrants close observation, it does not automatically indicate urinary retention. Oliguria can result from dehydration, hypovolemia, or decreased kidney function, but urinary retention specifically refers to the inability to empty the bladder despite the presence of urine and often the urge to void.

C. A client with elevated blood pressure and headache may be experiencing hypertension or other cardiovascular issues, but these symptoms are not primary risk factors for urinary retention. While hypertension can affect kidney function long-term, it does not acutely prevent bladder emptying.

D. A client who has undergone a surgical procedure requiring general anesthesia is at the greatest risk for urinary retention. General anesthesia can depress the central nervous system and inhibit bladder contractility, reducing the sensation of bladder fullness and delaying the ability to void postoperatively. Postoperative urinary retention is a common complication, especially after procedures involving the pelvic area or when opioids are used for pain management. This makes careful monitoring, assessment of bladder distention, and interventions such as bladder scanning or catheterization critical for preventing complications like bladder overdistension or infection.