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 A

Explanation

A. Obtaining apical and radial rates simultaneously allows the nurse to assess for a pulse deficit by comparing the two rates. A pulse deficit is present when the apical rate (heard with a
stethoscope) is greater than the radial rate (palpated at the wrist).

B. Palpating pulses in the lower extremities is not specific for assessing a pulse deficit and may not accurately reflect the cardiac output.

C. Checking blood pressure in left and right arms assesses for blood pressure differences but does not specifically address a pulse deficit.
D. Comparing the pulse strength in the upper extremities does not directly assess for a pulse deficit; simultaneous assessment of apical and radial rates is more appropriate.

A. Vest restraint B. Tongue blade C. Oxygen setup D. Neck brace E. Neck brace

Correct Answer is C

Explanation

A. Vest restraints are not appropriate for seizure precautions. Restraints are generally not recommended as the primary intervention for seizure management.
B. The use of tongue blades during a seizure is not recommended and could pose a risk of injury.
C. Oxygen setup is crucial for managing a client during and after a seizure to ensure proper oxygenation.
D. Neck brace is not necessary for seizure precautions and may pose a risk during a seizure episode.

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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

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