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 observes urine leaking from the insertion site, past the catheter. What is the nurse's first action?

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11ecbb05_cb7a_6781_b433_c7e14f651011_MD0009_00 Obstruction (eg, clots, sediment), kinking/compression of catheter tubing, bladder spasms, and improper catheter size can cause leakage of urine from the insertion site of an indwelling urinary catheter. The nurse's first action should be to assess for a mechanical obstruction by inspecting the catheter tubing (Option A). These interventions may alleviate obstruction: Remove kinking or compression of the catheter or tubing.Attempt to dislodge a visible obstruction by milking the 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. Remove kinking or compression of the catheter or tubing. Attempt to dislodge a visible obstruction by milking the 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. If these interventions fail, the nurse should then notify the health care provider (HCP) (Option C). (Option B) Irrigation is usually avoided as pus or sediment can be washed back into the bladder; however, it is sometimes prescribed to relieve an obstruction to urine flow. If there is a discrepancy in expected urine output compared with fluid intake, a blockage is suspected and a bladder scan is then performed to confirm the presence of urine in the bladder. (Option D) The client has the recommended size of catheter and balloon for an adult male. The HCP may prescribe removal and reinsertion of a different-size catheter if other measures fail to relieve obstruction. Educational objective: If leakage of urine is observed from the insertion site of an indwelling urinary catheter, the nurse should assess for obstruction, kinking, or compression of the catheter or drainage tubing; bladder spasms; and improper catheter size.

A 55-Year-Old Male Client Has a 16-Fr Indwelling Urethral Catheter