A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

Choice A reason: A bladder scan is the first step to assess urine retention noninvasively. It measures bladder volume, determining if the client is retaining urine post-catheter removal. This guides further interventions, preventing unnecessary procedures and addressing potential complications like urinary retention or bladder distention. Choice B reason: Increasing fluids without assessing bladder volume is premature and risky. If retention exists, more fluid could exacerbate bladder distention, causing discomfort or injury. Fluid management should follow confirmation of voiding ability, ensuring the bladder can empty effectively to avoid complications. Choice C reason: Assisting to the bathroom assumes the client can void, which may not be true post-catheter. Without confirming bladder function via a scan, this action risks missing retention, potentially leading to bladder overdistention or urinary tract complications, delaying appropriate intervention. Choice D reason: Inserting a straight catheter is invasive and should not be the first action. Without a bladder scan to confirm retention, catheterization risks unnecessary discomfort or infection. Noninvasive assessment precedes invasive interventions to ensure patient safety and appropriate management of post-catheter voiding issues.