A nurse is preparing to insert an indwelling urinary catheter for a patient.
What actions should the nurse plan to take?

Choice A rationale:

The statement “I do my wheelchair exercises sitting in my chair” is correct. Wheelchair exercises are designed to be performed while seated in a wheelchair. They help to maintain muscle strength and flexibility, which is crucial for individuals with paralysis.

Choice B rationale:

The statement “I use a suppository every night to have a bowel movement” is also correct. Individuals with paralysis often have difficulty with bowel movements due to lack of muscle control. Using a suppository can stimulate the rectum and induce a bowel movement. Choice C rationale:

The statement “I need to catheterize myself twice a day” indicates a need for further teaching. Individuals with paralysis from the waist down following a spinal cord injury typically need to perform intermittent self-catheterization every 4-6 hours, not just twice a day. This helps to prevent urinary tract infections and bladder overdistension.

Choice D rationale:

The statement “I carry a water bottle with me because I drink a lot of water” is correct. Drinking plenty of water is important for overall health and can help to prevent urinary tract infections, which are common in individuals who self-catheterize.

The correct answer is: B. Decreased deep tendon reflexes.

Choice A rationale: Wheezing is not typically associated with hyperkalemia. It is more commonly related to respiratory conditions.

Choice B rationale: Hyperkalemia can cause decreased deep tendon reflexes due to the effect of high potassium levels on nerve conduction and muscle function.

Choice C rationale: Hypoactive bowel sounds are not a common sign of hyperkalemia. They are more often associated with gastrointestinal issues.

Choice D rationale: Cerebral edema is not related to hyperkalemia. It is usually associated with conditions affecting the brain, such as trauma or infections.