A nurse is caring for a female client who requests a contraceptive diaphragm.
Which of the following actions should the nurse take first?
Supervise return demonstration of diaphragm use.
Determine the client’s knowledge about diaphragm use
Document the client’s level of understanding about potential adverse effects.
Teach the client how to insert the diaphragm
The Correct Answer is B
The correct answer is choice B. Determine the client’s knowledge about diaphragm use. This is the first action the nurse should take because it allows the nurse to assess the client’s readiness to learn, identify any knowledge gaps, and tailor the teaching to the client’s needs.
Some of the other choices are wrong because:
- Choice A. Supervise return demonstration of diaphragm use.
This is not the first action the nurse should take because it assumes that the client already knows how to use the diaphragm correctly and safely. The nurse should first teach the client how to insert, remove, and care for the diaphragm before asking for a return demonstration.
- Choice C. Document the client’s level of understanding about potential adverse effects.
This is not the first action the nurse should take because it is part of the evaluation phase of teaching, not the assessment phase. The nurse should first determine what the client knows and needs to know about diaphragm use and its possible risks and benefits.
- Choice D. Teach the client how to insert the diaphragm.
This is not the first action the nurse should take because it is part of the implementation phase of teaching, not the assessment phase. The nurse should first assess the client’s knowledge, motivation, and preferences before providing instruction on how to use the diaphragm.
A contraceptive diaphragm is a birth control device that prevents sperm from entering the uterus.
It is a small, soft silicone or rubber cup with a flexible rim that covers the cervix.
It is inserted into the vagina with spermicide before sex and is held in place by the pelvic muscles. It is a reusable type of contraception that women can use to avoid getting pregnant.
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Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. The nurse should choose a vein that is palpable and straight for IV catheter insertion.
This will facilitate the insertion of the catheter and reduce the risk of complications such as infiltration, phlebitis, or hematoma. A straight vein will also allow the catheter to be inserted up to the hub, which reduces the risk of contamination along the length of the catheter.
Choice A is wrong because selecting a site on the client’s dominant arm can interfere with the client’s mobility and increase the risk of dislodging the catheter. The nurse should choose a site on the client’s non-dominant arm, preferably on the hand or forearm.
Choice B is wrong because applying a tourniquet below the venipuncture site will impede blood flow and make it harder to locate a suitable vein. The nurse should apply a tourniquet above the venipuncture site, about 10 to 15 cm from the insertion site.
Choice C is wrong because elevating the client’s arm prior to insertion will decrease venous filling and make it harder to palpate a vein. The nurse should lower the client’s arm below the level of the heart to increase venous distension.
Normal ranges for IV catheter size and insertion angle depend on several factors, such as the type and duration of therapy, the condition and size of the vein, and the age and preference of the client.
In general, smaller gauge catheters (20 to 24) are preferred for peripheral IV therapy, and larger gauge catheters (14 to 18) are used for rapid fluid administration or blood transfusion. The insertion angle can vary from 10 to 30 degrees, depending on the depth and location of the vein.
Correct Answer is C
Explanation
The correct answer is choice C. Perform the procedure prior to meals.
This is because postural drainage involves positioning the child in different ways to help drain the mucus from the lungs.
If the child has a full stomach, this can cause nausea, vomiting, or aspiration. Therefore, the nurse should perform the procedure before meals or at least 1 hour after meals.
Choice A is wrong because the nurse should not hold the hand flat to perform percussions on the child.
Percussions are rhythmic clapping on the chest wall to loosen the mucus. The nurse should use a cupped hand to create a small air pocket that enhances the vibrations and prevents bruising.
Choice B is wrong because the nurse should not perform the procedure twice a day. The recommended frequency of postural drainage is 3 to 4 times a day, or more if needed, depending on the child’s condition and tolerance.
Choice D is wrong because the nurse should not administer a bronchodilator after the procedure.
A bronchodilator is a medication that relaxes and widens the airways, making it easier to breathe. The nurse should administer a bronchodilator before the procedure to enhance the effectiveness of postural drainage.
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