A client has not voided for 8 hours following the removal of an indwelling catheter. The nurse has clinically reasoned that the client may be experiencing urinary retention. Which of the following should be the nurse's first action?

Choice A rationale The first and most appropriate nursing action when suspecting urinary retention (no voiding for 8 hours after catheter removal) is to objectively assess the residual volume of urine in the bladder. A non-invasive bladder scan is the most effective and safest initial approach to confirm retention, quantify the volume, and avoid unnecessary catheterization or fluid administration, which could worsen discomfort and overdistend the bladder. Choice B rationale Inserting an indwelling catheter to remain in place for 24 hours is an invasive procedure that carries risks such as infection and should not be the first step. Catheterization is indicated only after confirming significant residual volume via a bladder scan and when less invasive methods fail, and a straight catheter is generally preferred for a one-time relief of retention. Choice C rationale Using a straight catheter (intermittent catheterization) is the correct intervention to alleviate confirmed urinary retention. However, it is an invasive procedure, and the nurse must first confirm the presence of significant retention using a non-invasive bladder scan before proceeding to catheterization for therapeutic relief. The bladder scan guides the need for this intervention. Choice D rationale Increasing both oral and intravenous fluid intake would increase urine production. If the client is truly retaining urine and cannot empty their bladder, increasing fluids will only lead to further bladder distension, increased discomfort, and potentially lead to injury to the bladder wall or the ureters and kidneys (hydronephrosis), making this action inappropriate as a first step.