# A postoperative client has not voided after catheter removal. Complete the nurse's evidence-based urinary-retention response.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=547008&lang=en  
> language: en  
> subject: Elimination  
> category: BCC

## Question

A postoperative client has not voided after catheter removal. Complete the nurse's evidence-based urinary-retention response.

The nurse should ::선택::wait until the next shift without assessmentrestrict fluids for 12 hoursinsert an indwelling catheter immediatelyassess voiding, medications, intake and output, mobility, and suprapubic findings, then ::선택::request abdominal radiographymeasure retained volume with bladder ultrasoundgive a loop diureticapply continuous suprapubic pressure. If protocol criteria are met, the nurse should ::선택::encourage repeated strainingleave the bladder distended overnightperform intermittent catheterization according to the nurse-driven protocolinsert a permanent catheter and should ::선택::avoid reflex indwelling recatheterization without a continuing indicationstop reassessment after one drainageignore recurrent retentionkeep the client on bed rest.

## Explanation

Postoperative urinary retention should be assessed promptly without automatically replacing an indwelling catheter. The nurse first evaluates symptoms, voiding history, mobility, medications, intake and output, and suprapubic findings, then uses bladder ultrasound according to the unit protocol to estimate retained volume. If the protocol threshold and symptoms indicate decompression, intermittent catheterization reduces unnecessary duration of indwelling catheter exposure. The nurse should also support privacy, positioning, mobility, and timed voiding when safe and reassess the pattern for persistent obstruction or neurologic dysfunction.

## In-depth explanation

Correct Answer
Assess, quantify retained urine with bladder ultrasound, use intermittent catheterization when protocol criteria are met, and avoid unnecessary indwelling catheter use.

Why It Fits
The client has symptoms of retention after catheter removal but no continuing indication for a chronic indwelling device.

Clinical Picture
Bladder ultrasound helps prevent both missed overdistention and catheterization when the bladder volume is low.

Memory Link
Scan before a tube; use the least persistent device that safely empties the bladder.

NCLEX Rule
Use protocols for postoperative retention and catheter-directed bladder management to minimize unnecessary indwelling catheter exposure.

Why the Alternatives Fail
Waiting despite progressive pressure or reflexively reinserting an indwelling catheter without assessment increases harm.

Sources
1CDC CAUTI Summary of Recommendations
2NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Postoperative unit
Six hours after an indwelling urinary catheter was removed, an adult has not voided and reports increasing suprapubic pressure. The client is hemodynamically stable, can stand with assistance, and has no chronic urinary catheter indication. The unit has a nurse-driven retention protocol.

## Key concepts

- **Postoperative urinary retention** — Inability to empty the bladder adequately after surgery or anesthesia.
- **Bladder ultrasound** — A noninvasive bedside estimate of bladder urine volume used to guide retention management.
- **Intermittent catheterization** — Temporary insertion and removal of a catheter to empty the bladder without leaving an indwelling device.

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