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.
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Related Questions
Correct Answer is C
Explanation
A. "Eat four small meals each day":
Eating smaller, more frequent meals can help prevent overfilling the stomach and reduce pressure on the lower esophageal sphincter (LES), potentially decreasing reflux symptoms. However, the effectiveness can vary among individuals.
B. "Sleep on your left side":
Sleeping on the left side may reduce symptoms of GERD for some individuals. This position can keep the stomach below the esophagus, minimizing reflux. However, individual preferences and comfort should be considered.
C. "Wait to go to bed for 1 hour after eating":
This instruction helps reduce the risk of reflux while lying down. Waiting after eating allows gravity to aid in digestion and reduces the likelihood of stomach contents backing up into the esophagus during sleep.
D. "Drink milk to soothe your stomach":
While milk might provide temporary relief for some people by neutralizing stomach acid, it can stimulate acid production, potentially exacerbating GERD symptoms in the long run. Therefore, it's not a recommended solution for managing GERD.
Correct Answer is B
Explanation
A. Blood glucose level below 40 mg/dL is not typical in diabetic ketoacidosis. DKA is characterized by hyperglycemia, and blood glucose levels are usually significantly elevated.
B. Acetone odor to breath is a classic sign of diabetic ketoacidosis. The presence of ketones, including acetone, can result in a fruity or sweet odor to the breath. This is often referred to as "ketone breath."
C. Malignant hypertension is not a typical manifestation of diabetic ketoacidosis. DKA is more commonly associated with dehydration, electrolyte imbalances, and metabolic acidosis.
D. Cheyne-Stokes breathing is not a characteristic respiratory pattern seen in diabetic ketoacidosis. Respiratory changes in DKA are more likely to involve rapid and deep breathing (Kussmaul respirations) as the body attempts to compensate for metabolic acidosis.
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