The male client complains of pain as the nurse is inflating the balloon following insertion of a Foley catheter. The nurse takes which of the following actions immediately?
1. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon.
2. Remove the catheter, and reinsert a new one that is one size smaller.
3. Finish inflating the balloon; the discomfort is normal and temporary.
4. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
4
Rationale: If the balloon is malpositioned in the urethra, balloon inflation could cause trauma and pain. If this occurs, the fluid should be aspirated and the catheter inserted a little farther to move the balloon past the neck of the urethra into the bladder. The catheter should not be withdrawn slightly ("aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon") because this will worsen the problem. There is no need to remove the catheter and reinsert a smaller one. The balloon should not continue to be inflated because the pain is not normal and will not go away.
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