1. A 55-year-old male client has a 16-Fr indwelling urethral catheter with a 5-mL balloon inserted
to relieve postoperative urinary retention. The nurse
... [Show More] observes urine leaking from the insertion
site, past the catheter. What is the nurse's first action?
1. Check the urethral catheter and
drainage tubing
2. Irrigate the catheter with 30 mL sterile
normal saline
3. Notify the health care provider
4. Remove and reinsert the next larger size
catheter
Obstruction (eg, clots, mucus, thick sediment) and kinking/compression of a catheter or tubing,
bladder spasms, and improper catheter or balloon size can cause leakage of urine from the insertion
site of an indwelling urinary catheter (Foley).
The nurse's first action should be to assess for a mechanical obstruction by inspecting the urethral
catheter and drainage tubing. The nurse should try to alleviate the causes of the obstruction of urine
from the bladder by performing the following as necessary:
Remove kinking or compression of the catheter or tubing
Attempt to dislodge a visible obstruction by milking the drainage tubing. This involves
squeezing and releasing the full length of the tubing, starting from a point close to the client
and ending at the drainage bag (Option 1).
If the above interventions fail, the nurse should notify the health care provider (HCP) (Option 3).
(Option 2) Irrigation is usually avoided because pus or sediments that may be present can be
washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to the
flow of urine. If there is a discrepancy in expected urine output compared to fluid intake, a blockage
of the urine flow is suspected and a bladder scan can be performed first to confirm the presence of
urine in the bladder. Furthermore, the nurse would not irrigate the catheter without a prescription
from the HCP, and so this is not the first action.
(Option 4) The client has the recommended size catheter and balloon for an adult male. The HCP
must provide a prescription for removal and reinsertion of a different-size catheter, so this is not the
first action.
Educational objective:
If leakage of urine is observed from the insertion site of an indwelling urinary catheter, the nurse
should assess for common causes that can impede the flow of urine. These include obstruction (eg,
clots, mucus, thick sediment), kinking, or compression of the catheter or drainage tubing; bladder
spasms; and improper catheter size [Show Less]