The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. The nurse notes the urine beginning to flow and next:
1. Immediately inflates the balloon
2. Inserts the catheter 2.5 to 5 cm farther, then inflates the balloon
3. Inserts the catheter until resistance is met, then inflates the balloon
4. Withdraws the catheter approximately 1 inch, then inflates the balloon
2
Rationale: The balloon is behind the opening at the catheter tip. The catheter is inserted 2.5 to 5 cm after urine begins to flow to provide sufficient space to inflate the balloon and to ensure that the balloon has passed through the entire urethra and into the bladder. Inflating the balloon in the urethra could produce trauma. The catheter should be neither withdrawn nor advanced until re-sistance is met.
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