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The Nurse Is Caring for a Client Who Returns to the Unit

Question 90

Multiple Choice

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."

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