CMSRN Medical-Surgical Nursing

Category - Genitourinary

The indwelling Foley catheter was removed following an episode of prostatitis, but the client did not void for the next 8 hours, even when allowed to stand. The best action for the nurse to take is to:
  1. Ask the physician for a prostate evaluation
  2. Wait another 8 hours and encourage frequent attempts
  3. Ask the physician for orders to catheterize the bladder
  4. Encourage oral fluids and hot baths to relax the sphincter
Explanation
Answer - C - Not voiding for 8 hours may result in infection, as well as more severe problems. A straight catheterization may be done or the Foley reinserted to allow for bladder reflexes to recover. Choice A is incorrect because the potential for bladder distention will not be relieved by a prostate evaluation. Choice B is incorrect because waiting can result in severe bladder distention, infection, damage to the kidneys, and even bladder rupture. Choice D is incorrect because increasing oral intake does not correct the inability to void.
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