A nurse is ready to insert an indwelling urinary catheter for a female client. Which of the following instructions should the nurse provide to the client as the catheter is inserted?
Bear down.
Exhale slowly.
Contract the pelvic muscles.
Take a sip of water.
The Correct Answer is A
Correct answer: A
A. Bear down:
Bear down: Asking the client to bear down gently (as if to void) helps to expose urethral meatus.Bearing down simulates the act of urination and helps open the urethra.
B. Exhale slowly:
While exhaling slowly might help the client relax, it does not specifically assist with the insertion of the catheter as effectively as bearing down.
C. Contract the pelvic muscles:
Contracting the pelvic muscles (such as squeezing or tightening) might make catheter insertion more challenging by tensing the area where the catheter needs to pass through.
D. Take a sip of water:
Drinking water is not typically instructed during urinary catheter insertion, as it's unrelated to the process and might increase discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Regular insulin:
Regular insulin, also known as short-acting insulin, is commonly used in the initial management of diabetic ketoacidosis. It has a relatively rapid onset of action, making it suitable for addressing the acute and severe nature of DKA.
B. Insulin detemir:
Insulin detemir is a long-acting insulin analog. It is not the preferred choice for addressing the acute insulin needs in DKA; instead, it is used for basal insulin requirements in the maintenance phase of diabetes management.
C. Insulin glargine:
Insulin glargine is a long-acting insulin analog used for basal insulin coverage. Like insulin detemir, it is not the first choice for addressing the acute insulin needs in the initial treatment of DKA.
D. NPH insulin:
NPH (Neutral Protamine Hagedorn) insulin is an intermediate-acting insulin. While it has a role in diabetes management, it is not the preferred choice for the initial treatment of DKA. NPH insulin has a slower onset and longer duration compared to regular insulin.
Correct Answer is D
Explanation
A. Investigate the client's emotional concerns:
While addressing emotional concerns is important, assessing electrolyte imbalances and physiological stability takes precedence in managing an acute exacerbation of ulcerative colitis.
B. Check the client's perianal skin integrity:
Assessing perianal skin integrity is crucial, especially in inflammatory bowel disease, but it might not be the immediate priority compared to evaluating electrolyte imbalances.
C. Obtain a dietary history from the client:
Although dietary history is relevant for managing ulcerative colitis, the urgency lies in assessing and managing potential electrolyte imbalances due to the exacerbation of the condition.
D. Review the client's electrolyte values:
This is the correct action. During an acute exacerbation of ulcerative colitis, the client is at risk of electrolyte imbalances due to diarrhea, dehydration, and potential fluid and electrolyte losses. Promptly reviewing the electrolyte values helps identify any imbalances that might require immediate intervention.
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