A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to help ease the passage of the catheter through the urinary meatus?

"Raise your head off the pillow."

"Bear down."

"Hold your breath."

"Perform Kegel exercises."

Answer and Explanation

The Correct Answer is B

A.   Raising the head off the pillow is not relevant to easing the passage of the catheter through the urinary meatus.
B.   Bearing down can help relax the pelvic floor muscles, making it easier to insert the catheter through the urinary meatus.
C.   Holding the breath is not typically instructed during catheter insertion and may not aid in the ease of the procedure.
D.   Performing Kegel exercises involves contracting pelvic floor muscles, which is not the desired action when inserting a urinary catheter.

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Correct Answer is C

Explanation

A. Sterile gloves are not necessary for a tap water enema; clean, non-sterile gloves are sufficient.

B. Lubricating the tip of the rectal tube is appropriate to ease insertion and enhance client comfort.
C. Placing the client into a left Sims' position facilitates optimal administration of a tap water enema.
D. Lowering, not raising, the enema bag will allow for a slower flow and may reduce cramping.

A. Giving oral care to a client who cannot take oral fluids B. Checking intravenous insertion sites for signs of infiltration C. Assessing a client's ability to ambulate D. Demonstrating to a client with diabetes mellitus how to use the glucometer

Correct Answer is A

Explanation

A. Giving oral care to a client who cannot take oral fluids is a task that can be safely delegated to an assistive personnel.
B. Checking intravenous insertion sites for signs of infiltration requires nursing judgment and assessment skills and should be performed by a licensed nurse.
C. Assessing a client's ability to ambulate involves clinical judgment and should be performed by a licensed nurse.
D. Demonstrating how to use a glucometer to a client with diabetes requires nursing knowledge and education skills and should be performed by a licensed nurse.

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A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to help ease the passage of the catheter through the urinary meatus?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a tap water enema to a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse should assign which of the following tasks to an assistive personnel?

Correct Answer is A

Explanation

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