NCLEX-RNBasic Care and ComfortMedium
A nurse performs a bladder scan on a client who reports difficulty voiding after removal of an indwelling catheter. The scan shows a post-void residual (PVR) of 480 mL. What should the nurse do next?
- ANotify the provider and prepare to perform intermittent straight catheterization
- BEncourage the client to increase oral fluid intake and recheck in 8 hours
- CDocument the finding as normal and continue to monitor intake and output
- DApply gentle suprapubic pressure to assist the client with voiding
Show answer & explanationAnswer & explanation
Correct answer: A. Notify the provider and prepare to perform intermittent straight catheterization
A PVR greater than 200 mL after voiding indicates significant urinary retention and requires straight catheterization to prevent bladder distension, infection, and renal damage. The provider should be notified so orders can be obtained.
Why the other options are wrong
- B. Increasing fluids does not resolve retention and delays needed treatment.
- C. A PVR of 480 mL is well above normal (<50-100 mL) and requires intervention.
- D. Suprapubic pressure (Credé) is not sufficient for this degree of retention and is not standard practice.
Post-Void Residual (PVR)
The volume of urine remaining in the bladder after voiding, used to assess urinary retention.
- Normal PVR is less than 50-100 mL
- PVR greater than 200 mL generally requires catheterization
- Retention increases risk for UTI and bladder/kidney damage
Memory trick: Two hundred is the line — cross it and it's cath time.