a nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter which of the following actions s
Logo

Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: Performing a bladder scan is the first step to assess bladder retention before any further interventions.

2. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?

Correct answer: C

Rationale: The correct precaution for a nurse caring for a client with shigella-induced diarrhea is to wash hands before and after client care. Shigella is a highly contagious bacterium that spreads through contaminated food, water, or contact with infected individuals. While wearing gloves is important when directly handling bodily fluids, hand hygiene is crucial in preventing the transmission of the infection. Wearing a mask or using an N95 respirator is not necessary for preventing the spread of shigella, as it primarily spreads through the fecal-oral route rather than through respiratory droplets.

3. A nurse is preparing to administer morphine sulfate to a client. What should the nurse assess before administration?

Correct answer: B

Rationale: Correct answer: Before administering morphine sulfate, the nurse should monitor for respiratory depression as it is a significant side effect of this medication. Assessing for pain relief (Choice A) is important but not a pre-administration assessment. Checking the infusion site for complications (Choice C) is relevant for IV medications, not specifically for morphine sulfate. Increasing the dosage if the client reports more pain (Choice D) is not appropriate without further assessment and medical orders.

4. How should a healthcare provider manage a patient with deep vein thrombosis (DVT)?

Correct answer: A

Rationale: Corrected Rationale: Monitoring for signs of pulmonary embolism is crucial in patients with deep vein thrombosis (DVT) as it can be a life-threatening complication. While administering anticoagulants as prescribed is important for preventing clot progression, the immediate concern is detecting potential pulmonary embolism. Applying compression stockings and encouraging leg elevation are beneficial measures for managing DVT symptoms but are not as critical as monitoring for pulmonary embolism.

5. A nurse is preparing to administer medications to four clients. The nurse should administer medications to which client first?

Correct answer: B

Rationale: The correct answer is B. The client with renal failure and high potassium levels requires immediate attention because hyperkalemia can lead to life-threatening cardiac complications. Administering sodium polystyrene sulfonate helps lower the potassium levels. Choice A, the client with pneumonia and a high WBC count, although important, does not present an immediate life-threatening condition. Choice C, the post-CABG client prescribed atorvastatin, and Choice D, the client with anemia and a hemoglobin level of 11g/dL prescribed epoetin alfa, do not require immediate intervention compared to managing hyperkalemia in a client with renal failure.

Similar Questions

A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
Which intervention is most effective in preventing postoperative complications?
What is the priority intervention for a patient experiencing chest pain?
While caring for a client receiving morphine, what assessment is the priority for a nurse to conduct?
When assessing a client with terminal cancer receiving a continuous intravenous infusion of morphine sulfate, what should the nurse check first?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses