Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. "Raise your head off the pillow."
Raising the head off the pillow is not relevant to easing the passage of the catheter through the urinary meatus.
B. "Bear down."
Bearing down can help relax the pelvic floor muscles, making it easier to insert the catheter through the urinary meatus.
C. "Hold your breath."
Holding the breath is not typically instructed during catheter insertion and may not aid in the ease of the procedure.
D. "Perform Kegel exercises."
Performing Kegel exercises involves contracting pelvic floor muscles, which is not the desired action when inserting a urinary catheter.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Fundamentals Proctored Exam 6. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is teaching a client who is to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The nurse should inform the client that TENS relieves pain by
A. providing distraction from the pain.
TENS does not primarily work by providing distraction from pain.
B. eliciting a relaxation response.
While relaxation may be a secondary effect, the primary mechanism of TENS is not to elicit a relaxation response.
C. modulating the transmission of the pain impulse.
TENS works by modulating the transmission of the pain impulse, disrupting pain signals from reaching the brain.
D. promoting increased circulation to the painful area.
TENS does not primarily work by promoting increased circulation to the painful area.
Full Explanation
A. TENS does not primarily work by providing distraction from pain.
B. While relaxation may be a secondary effect, the primary mechanism of TENS is not to elicit a relaxation response.
C. TENS works by modulating the transmission of the pain impulse, disrupting pain signals from reaching the brain.
D. TENS does not primarily work by promoting increased circulation to the painful area.
A nurse should assign which of the following tasks to an assistive personnel?
A. Giving oral care to a client who cannot take oral fluids
Giving oral care to a client who cannot take oral fluids is a task that can be safely delegated to an assistive personnel.
B. Checking intravenous insertion sites for signs of infiltration
Checking intravenous insertion sites for signs of infiltration requires nursing judgment and assessment skills and should be performed by a licensed nurse.
C. Assessing a client's ability to ambulate
Assessing a client's ability to ambulate involves clinical judgment and should be performed by a licensed nurse.
D. Demonstrating to a client with diabetes mellitus how to use the glucometer
Demonstrating how to use a glucometer to a client with diabetes requires nursing knowledge and education skills and should be performed by a licensed nurse.
Full Explanation
A. Giving oral care to a client who cannot take oral fluids is a task that can be safely delegated to an assistive personnel.
B. Checking intravenous insertion sites for signs of infiltration requires nursing judgment and assessment skills and should be performed by a licensed nurse.
C. Assessing a client's ability to ambulate involves clinical judgment and should be performed by a licensed nurse.
D. Demonstrating how to use a glucometer to a client with diabetes requires nursing knowledge and education skills and should be performed by a licensed nurse.
A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1,200 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr?
(Round the answer to the nearest whole number. Use a leading zero is applicable. Do not use a trailing zero.)
Full Explanation
The question is about calculating the IV infusion rate for a given solution and volume.
The formula for the infusion rate is: (volume in mL / time in hours) x drop factor in gtts/mL = infusion rate in gtts/min
The drop factor is usually given on the IV tubing package and varies depending on the type of tubing used.
For this question, we can assume a drop factor of 15 gtts/mL, which is common for macrodrip tubing.
Plugging in the numbers, we get: (1200 mL / 8 hr) x 15 gtts/mL = 2250 gtts/hr
To convert from gtts/hr to mL/hr, we divide by the drop factor: 2250 gtts/hr / 15 gtts/mL = 150 mL/hr
Therefore, the nurse should set the IV pump to deliver 150 mL/hr.