Question

which intervention is most important for the nurse to implement for a client who is experiencing urinary retention
a insert a urinary catheter.
b encourage increased fluid intake.
c assess for bladder distention.
d apply a skin protectant.

Explanation:

For a client with urinary retention, the first priority is to confirm the presence and severity of bladder distention, as this is the key assessment to guide subsequent interventions. Inserting a catheter is an intervention that comes after confirming distention, increased fluid intake may worsen retention if the bladder is already full, and skin protectant is a secondary measure for skin integrity, not the most initial critical step.

Answer:

C. Assess for bladder distention.