a nurse is caring for a client who has an indwelling urinary catheter which of the following actions should the nurse take to prevent infection
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HESI LPN

Practice HESI Fundamentals Exam

1. A client has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

Correct answer: B

Rationale: Cleaning the perineal area with antiseptic solution daily is essential to prevent infection when caring for a client with an indwelling urinary catheter. This practice helps reduce the risk of introducing pathogens into the urinary tract. Ensuring the catheter tubing is free of kinks (Choice A) is important for maintaining proper urine flow but is not directly related to preventing infection. Irrigating the catheter with normal saline every shift (Choice C) is not a routine practice and can increase the risk of introducing pathogens. Securing the catheter to the client's leg (Choice D) is important for stability but does not directly prevent infection.

2. A client with a history of alcoholism is admitted with confusion and ataxia. The LPN/LVN recognizes that these symptoms may be related to a deficiency in which vitamin?

Correct answer: D

Rationale: The correct answer is Vitamin B1 (Thiamine). Vitamin B1 deficiency, also known as Thiamine deficiency, is common in clients with a history of alcoholism. Thiamine is essential for proper brain function, and its deficiency can lead to neurological symptoms such as confusion and ataxia. Vitamin A, C, and D deficiencies do not typically present with confusion and ataxia in the context of alcoholism. Vitamin A deficiency mainly affects vision, Vitamin C deficiency leads to scurvy with symptoms like bleeding gums, and Vitamin D deficiency is associated with bone disorders. Therefore, they are not the correct choices in this scenario.

3. When caring for a client with diarrhea due to Shigella, which of the following precautions should the nurse take?

Correct answer: A

Rationale: The correct precaution for Shigella infection is to wash hands thoroughly before and after contact with the client. Shigella is transmitted through the fecal-oral route, so hand hygiene is crucial in preventing its spread. Wearing a surgical mask or face shield is not necessary for Shigella as it is not primarily transmitted through respiratory droplets. While wearing a gown and gloves is important for standard precautions, the key precaution specific to Shigella is proper hand hygiene.

4. A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection?

Correct answer: B

Rationale: A client who has tuberculosis requires airborne precautions, including placing the client in a room with negative-pressure airflow to reduce the risk of infection transmission. Choices A, C, and D are incorrect. Carrying soiled linens in a mesh bag, providing disposable plates and utensils for an HIV-positive client, and disposing of blood-saturated dressing in a biohazard bag do not specifically address preventing the spread of tuberculosis, which requires airborne precautions.

5. A community health nurse is caring for a group of families. The nurse should identify which of the following families is experiencing a maturational loss?

Correct answer: D

Rationale: The correct answer is D because maturational loss is related to developmental changes, such as children leaving for college. This type of loss is tied to the normal life transitions of individuals and can lead to feelings of grief and adjustment. Choices A, B, and C represent different types of losses. Choice A involves a traumatic loss of a child due to illness, choice B involves a financial loss impacting the head of household's job, and choice C involves a material loss due to a fire incident. While these losses are significant, they do not specifically relate to maturational loss, which is associated with expected life stage transitions.

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