Fundamentals of Nursing Q 241
A client who has an indwelling catheter reports the need to urinate. Which of the following interventions should the nurse perform?
A. Check to see whether the catheter is patent.
B. Reassure the client that it is not possible for her to urinate.
C. Re-catheterize the bladder with a larger gauge catheter.
D. Collect a urine specimen for analysis.
Correct Answer: A. Check to see whether the catheter is patent.
A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate. An indwelling urinary catheter (IUC), generally referred to as a “Foley” catheter, is a closed sterile system with a catheter and retention balloon that is inserted either through the urethra or suprapubically to allow for bladder drainage. External collecting devices (e.g. drainage tubing and bag) are connected to the catheter for urine collection.
Option B: Reassuring the client that it is not possible to urinate is a non-therapeutic response because it diminishes the client’s concern. Check the tube once in a while for bends or kinks that keep pee from flowing out. Empty the leg bag twice a day or when it’s half full. Keep the drainage bag below your bladder so it drains well.
Option C: There are less invasive approaches the nurse can take before replacing the catheter. Indwelling urinary catheters are recommended only for short-term use, defined as less than 30 days (EAUN recommends no longer than 14 days.) The catheter is inserted for continuous drainage of the bladder for two common bladder dysfunction: urinary incontinence (UI) and urinary retention.
Option D: Although it may become necessary to collect a urine specimen, there is a simpler approach the nurse can take to assess and possibly resolve the client’s problem.