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. Avoid foods high in fat:
Dietary fat can trigger the gallbladder to release bile, and for individuals with chronic cholecystitis, high-fat meals can exacerbate symptoms such as biliary colic. Therefore, advising the client to avoid foods high in fat can help manage symptoms.
B. Include foods high in starch and proteins:
While protein-rich foods can be included in the diet, a high-fat content should be avoided. Starches can be a part of a balanced diet, but it's essential to focus on low-fat options.
C. Include foods high in fiber:
Including foods high in fiber is generally a good recommendation for digestive health. However, the emphasis here is on avoiding high-fat foods, and the recommendation for fiber should not overshadow the importance of minimizing dietary fat.
D. Avoid foods high in sodium:
Sodium restriction may be relevant for certain health conditions, but it is not the primary dietary consideration for managing chronic cholecystitis. The emphasis in this context is on reducing dietary fat.
Correct Answer is B
Explanation
A. Testing the client's emesis for blood is an important assessment, but assessing orthostatic blood pressure is a priority. Orthostatic blood pressure measurement helps identify if the client is experiencing significant blood loss, as changes in blood pressure upon standing may indicate hypovolemia.
B. Assessing orthostatic blood pressure is the priority action. Orthostatic hypotension can be a sign of decreased circulating blood volume, which is a concern in clients with gastrointestinal bleeding.
C. Explaining the procedure for an upper gastrointestinal series is not the first priority. While diagnostic tests may be needed, addressing the immediate concern of potential hypovolemia takes precedence.
D. Administering pain medication is not the first action. The priority is to assess and address the potential complications of gastrointestinal bleeding, such as hypovolemia.
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