The nurse is caring for a client who returns to the unit following transurethral resection of the prostate due to prostate cancer with a three-way Foley catheter in place.
The client states that he has the urge to urinate and wants the catheter removed. The nurse knows that this feeling is caused by spasms. Which response by the nurse is the most appropriate?
A) This must be a complication, because the Foley catheter is supposed to evacuate clots that cause the sensation you are describing.
B) The spasm is an unexpected finding because the procedure does not invade the urethra.
C) The sensation is caused by the silicone used in the catheter. I will speak to the doctor about switching to a different catheter.
D) This is an expected sensation, but the Foley catheter must remain in place.
Question 2
The nurse is caring for a client who has a continuous bladder irrigation running following a prostatectomy. During the shift, a total of 1500 mL of irrigant is infused.
The Foley bag is emptied twice for the shift with totals of 850 mL and 950 mL. What is the client's actual urine output for the shift?
A) 300 mL
B) 250 mL
C) 100 mL
D) 950 mL
Weber test: Place the base of the tuning fork on top of the client’s head.
The basic unit of life - cell
Intervention Model-Response to Client Misconduct
Measuring the client’s weight with a standard platform scale
Survey and posture of client: Lateral view
Positioning the client