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."
Answer: D
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.
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