The nurse observes the external genitalia of a female client in preparation for inserting an indwelling urinary catheter. At which location should the catheter be inserted? (Mark location on image)
A
B
C
D
The Correct Answer is B
A. Clitoris: This is a highly sensitive erectile tissue and not connected to the urinary system.
B. Urethra: This is the correct site for catheter insertion, as it leads directly into the urinary bladder.
C. Labia: These are external folds of skin that surround the urethral and vaginal openings, not the site for catheter insertion.
D. Vagina: Inserting a catheter here would result in incorrect placement. The vagina is posterior to the urethra.
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Related Questions
Correct Answer is C
Explanation
A. Tenderness: Tenderness during percussion could indicate an underlying issue, such as inflammation or infection, and is not a normal finding.
B. Pain: Pain during percussion may suggest problems like organ inflammation or distension and is not considered normal.
C. Musical and drumlike: This finding is normal and is often indicative of the presence of air or gas in the intestines, which is a common finding in older adults, especially those with less efficient digestion.
D. Absent sounds: Absent sounds could indicate bowel obstruction or other serious issues and are not a normal finding. Normal percussive sounds should be heard.
Correct Answer is ["1350"]
Explanation
Rationale:
Fluid resuscitation rate using the Parkland formula:
- Calculate the total fluid volume needed for the first 24 hours.
The Parkland formula: 4 mL × client weight (kg) × % TBSA burned.
Client weight = 90 kg
TBSA burned = 45%
Total fluid volume = 4 mL × 90 kg × 45 = 16,200 mL
- Determine the amount of fluid to be given in the first 8 hours.
According to the Parkland formula, half of the total fluid volume is administered in the first 8 hours from the time of the burn injury.
Fluid for first 8 hours = 16,200 mL / 2
= 8,100 mL
- Calculate the infusion rate for the first 8 hours.
The burn occurred at 1000. The nurse arrives at 1200. This means 2 hours have already passed since the burn occurred within the initial 8-hour period.
Remaining time in the first 8 hours = 8 hours - 2 hours
= 6 hours.
Infusion rate (mL/hour) = Fluid for remaining first 8 hours / Remaining time in first 8 hours
= 8,100 mL / 6 hours
= 1350 mL/hour.
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