Evolve HESI Practice Exam

What is the most important intervention for a male client experiencing urinary retention?

1. Encourage hydration and fluid intake

2. Assess for bladder distention

3. Administer a diuretic as prescribed

4. Perform bladder training techniques

The correct answer is: Assess for bladder distention

Assessing for bladder distention is crucial in managing urinary retention because it helps to determine the severity of the condition. When a client is experiencing urinary retention, the bladder may become overly full which can lead to discomfort, potential damage to the bladder, and an increased risk of urinary tract infections. By assessing for bladder distention, a healthcare professional can gauge how much urine is present in the bladder, guiding subsequent interventions. Recognizing the degree of distention can also aid in deciding whether to perform a catheterization, which might be needed to relieve the retention. This assessment ensures that appropriate and timely action is taken to relieve the discomfort and prevent complications related to prolonged bladder retention. Effective management begins with a thorough assessment, making it a foundational step in intervention. While other choices, such as encouraging hydration or performing bladder training techniques, are valuable in managing urinary needs, they are secondary to the immediate assessment of the client's condition. Administering a diuretic might not be appropriate in cases of urinary retention, especially if the underlying cause needs to be identified first. Thus, starting with an accurate assessment is key in forming an effective plan of care for the client.