A client returns to the unit following transurethral resection of ...

[cnetterville]

A client returns to the unit following transurethral resection of the prostate due to prostate cancer. The client states that he wants the three-way Foley catheter to be removed because it is causing him to have bladder spasms.
 
  Which of the following is the best response by the nurse? 1. Spasms are painful but expected because of the wide diameter of the catheter and the retention balloon in the bladder..
   2. This must be a complication, because the Foley catheter is supposed to evacuate clots that cause spasms..
   3. The spasm is an unexpected finding because the procedure does not invade the urethra..
   4. Foley catheters in general have a tendency to cause bladder spasms because of the silicone used in the catheter..

Question 2

The nurse cannot palpate a client's pedal pulse following an open reduction internal fixation procedure for a fractured tibia. Which of the following is a priority intervention for this client?
 
  1. Notify the surgeon of the problem
   2. Check the lower extremity for pallor
   3. Use a Doppler ultrasound to find the pedal pulse
   4. Assess the client's pain rating

[Liddy]

Answer to Question 1

1. Spasms are painful but expected because of the wide diameter of the catheter and the retention balloon in the bladder..

Rationale:
Clients with a three-way Foley catheter usually complain of sensations of having to void despite the presence of the catheter. This urge to void is caused by the pressure exerted by the balloon in the internal sphincter of the bladder and the wide diameter of the catheter that is used for the purpose of irrigation. Antispasmodics may be prescribed for the client with a three-way irrigation catheter. Spasms are not a complication of the catheter but rather, an expected finding. The procedure does invade the urethra. The substance that the catheter is made of does not affect spasms.

Answer to Question 2

3. Use a Doppler ultrasound to find the pedal pulse

Rationale:
To assess for circulation when the pulse is not palpable, the nurse next should use a Doppler ultrasound. Notifying the surgeon should occur once all assessment data are collected; this can include the presence of pallor and pain.

[cnetterville]

TYSM

[Missbam101]

Excellent