A nurse is caring for a client who has not voided for 8 hours after removing an indwelling urinary catheter. What is the nurse's first action?

The first action a nurse should take when a client has not voided for 8 hours following the removal of an indwelling urinary catheter is to perform a bladder scan. This ultrasound-based assessment helps determine the volume of urine in the bladder, which is crucial in evaluating whether the client is facing urinary retention. If there is a significant amount of urine present, the scan provides important information to guide subsequent interventions, such as catheterization if necessary.

While checking vital signs, encouraging fluid intake, and palpating the bladder may all be relevant assessments in the context of urinary retention, they do not provide immediate, quantifiable information about the bladder's contents. A bladder scan specifically addresses the concern of urinary retention in a direct and effective manner. It helps to quickly assess the situation and decide on further actions based on the findings.