Practice Quiz

NCLEX-RN

Category - Reduction of Risk

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An 80-year-old male client diagnosed with benign prostate hypertrophy complains of pain as the nurse inflates the balloon of the indwelling urethral catheter being inserted into the client’s urethra. What is the best action of the nurse?
  1. Aspirate the fluid, withdraw the catheter, and reinflate the balloon.
  2. Aspirate the fluid, advance the catheter, and reinflate the balloon,
  3. Remove the syringe and begin after care. Pain is an expected response.
  4. Aspirate the fluid, remove the catheter, and replace it with a smaller catheter.
Explanation
Answer - B - If pain occurs during balloon inflation, it indicates that the balloon needs to be repositioned. The best action is to aspirate the fluid, advance the catheter further, and reinflate the balloon. Advancing the catheter allows space for balloon inflation.
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