A client taking morphine sulfate for acute pain has not voided in 6 hours. The nurse suspects the client has developed urinary retention. What is the priority nursing intervention?

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Opioids (eg, morphine sulfate), anticholinergic medications, and tricyclic antidepressants can cause urinary retention; they increase bladder sphincter tone and/or relax bladder muscle. The nurse should assess the client's suprapubic area to determine if the client has urinary retention. If the area is distended and dull to percussion, the nurse should proceed with interventions. (Option A) While asking if a bedpan is needed is an important nursing intervention, it does not aid in the assessment of urinary retention. (Option B) Gathering assessment data indicating the presence of urinary retention is necessary prior to other interventions. The nurse should assess for fluid intake after assessing bladder distension. (Option C) The client's skin turgor is assessed after the nurse checks for urinary retention and fluid intake. There is no need to assess skin turgor until other indicators of adequate fluid intake are reviewed. Educational objective: Assessing the client's suprapubic area is the priority nursing action when urinary retention is suspected. Interventions are performed after a problem is identified and its cause is determined. Urinary retention is an expected side effect of opioid medications.

A Client Taking Morphine Sulfate for Acute Pain Has Not