A 72-year-old male with severe benign prostatic hyperplasia has not voided for 14 hours and presents with acute agonizing suprapubic pain. Bedside bladder ultrasound scan demonstrates 1,200 mL of retained urine. The nurse prepares to insert a Foley catheter. To avoid transient hematuria and bladder spasm from rapid decompression, what clinical practice should the nurse observe?

Answer and explanation

Correct answer: D. Allow gradual urine decompression and monitor for post-obstructive diuresis and hypotension

  1. Step 1: Acute urinary retention with large residual volumes (> 1000 mL) requires urinary catheter decompression.
  2. Step 2: Rapid relief of prolonged high intravesical pressure can precipitate post-obstructive diuresis, transient hematuria (ex vacuo), and vasovagal hypotension; nurses must monitor urine output, vital signs, and electrolytes closely following catheterization.
Answer
Allow gradual urine decompression, monitoring for post-obstructive diuresis and hypotension.
Why not the others: 'Drain full 1,200 mL in less than 30 seconds' exacerbates mucosal bleeding and vasovagal collapse; 'Refuse catheter insertion' leaves the patient in severe agonizing pain and risks bladder rupture; 'Clamping permanently after 100 mL' fails to relieve the obstruction.

Practise more Primary Nursing, Acute Patient Assessment and Triage.

Free questions with an explanation for every one, and full timed MOH Prometric mock tests.

All Primary Nursing, Acute Patient Assessment and Triage questionsTake a mock test

More Primary Nursing, Acute Patient Assessment and Triage questions