After observing urine flow in the tubing during indwelling catheter insertion, which action should the nurse take next?

After observing urine flow in the tubing during indwelling catheter insertion, which action should the nurse take next?

• A. Inflate the balloon with 5 ml of sterile water.
• B. Document the color and clarity of the urine.
• C. Ask the client to breathe deeply and slowly exhale.
• D. Insert the catheter an additional inch.

Answer: (D)

When urine begins to flow, you’re in the bladder region, but you want the catheter tip to be fully in the bladder before inflating the balloon. Advancing the catheter about one inch ensures the tip is not still in the urethra and positions the balloon correctly within the bladder. After you’ve advanced, you can inflate the balloon with sterile water to secure the catheter and then proceed with final checks.

When urine begins to flow, you’re in the bladder region, but you want the catheter tip to be fully in the bladder before inflating the balloon. Advancing the catheter about one inch ensures the tip is not still in the urethra and positions the balloon correctly within the bladder. After you’ve advanced, you can inflate the balloon with sterile water to secure the catheter and then proceed with final checks.