An older adult woman has just been admitted to a long-term care center. The EMT discloses the client has not had urine output for the last 8 hours per the shift report provided to them. Which of the following should be the nurse's priority action?

Choice A rationale Placing an indwelling catheter is an invasive procedure that carries a significant risk of urinary tract infection, especially in older adults. It should only be performed after less invasive diagnostic measures have confirmed the presence of retained urine and other interventions have failed. Jumping straight to catheterization violates the principle of using the least invasive intervention first and does not provide diagnostic information regarding why the output has ceased over the last eight hours. Choice B rationale Performing a bladder scan is the priority action because it is a non-invasive bedside diagnostic tool that immediately quantifies the volume of urine in the bladder. Normal post-void residual is typically less than 50 mL to 100 mL. This assessment helps the nurse differentiate between urinary retention, where the bladder is full but cannot empty, and decreased urine production, which might indicate dehydration or renal failure. Assessment must always precede intervention in the nursing process. Choice C rationale Asking the client to increase fluid intake is an intervention that should only be implemented once the cause of the low urine output is determined. If the client is suffering from urinary retention due to an obstruction, such as an enlarged prostate or a blockage, increasing fluids will exacerbate the bladder distension and increase discomfort or risk of bladder injury. The nurse must first use a bladder scan to determine if urine is actually present. Choice D rationale Intermittent catheterization is an intervention used to drain the bladder when a client cannot void spontaneously. While it has a lower risk of infection than an indwelling catheter, it is still an invasive procedure. The nurse should first perform a non-invasive bladder scan to confirm that the bladder contains enough urine to warrant catheterization. Without an initial assessment of bladder volume, this action is premature and could cause unnecessary discomfort or risk for the patient.