The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a healthcare-associated infection?

A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.

B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.

C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.

D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.

A. "Patient with complaints of urinary incontinence." The patient did not report involuntary leakage of urine, which defines incontinence.
B. "Patient reports urinary retention." Urinary retention refers to the inability to completely empty the bladder, which matches the patient's description.
C. "Patient reports urinary frequency." Urinary frequency means voiding frequently (e.g., every 1-2 hours), but the patient described difficulty emptying.
D. "Patient has an enlarged prostate." While an enlarged prostate (BPH) could cause retention, the nurse should not diagnose—only report symptoms.