a nurse is preparing to discontinue a clients indwelling urinary catheter which of the following actions should the nurse take first

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

A. Measure and document the urine in the drainage bag
B. Remove the tape or device securing the catheter to the client's thigh
C. Position the client supine
D. Deflate the catheter balloon using a sterile syringe

Correct answer: A

Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.

2. When is removal of the restraints by the nurse appropriate?

A. When medication that has been administered has taken effect
B. When no acts of aggression are observed in the hour following the release of two extremity restraints
C. When the nurse explores with the client the reasons for the angry and aggressive behavior
D. When the client apologizes and tells the nurse that it will never happen again

Correct answer: B

Rationale: The correct answer is B. The nurse can safely remove restraints once no aggressive behavior is observed after releasing two extremity restraints for an hour. Choice A is incorrect because the removal of restraints should be based on the client's behavior rather than just the effect of medication. Choice C is incorrect as exploring reasons for aggressive behavior should be done before or during the intervention, not as a condition for removing restraints. Choice D is incorrect since an apology from the client does not guarantee a change in behavior or indicate that it is safe to remove the restraints.

3. A nurse is preparing a client for surgery. The client refuses to remove a religious medal. What is the nurse's best response?

A. Ask the family to remove the medal
B. Place the medal in a safe place for the client
C. Allow the client to keep the medal during surgery
D. Inform the client that the medal must be removed

Correct answer: C

Rationale: The correct answer is to allow the client to keep the medal during surgery. Clients may retain religious medals or jewelry during surgery if it does not interfere with the procedure. Asking the family to remove the medal (Choice A) may not be respecting the client's wishes. Placing the medal in a safe place for the client (Choice B) may cause distress to the client who wants to keep it. Informing the client that the medal must be removed (Choice D) disregards the client's beliefs and preferences.

4. A client with a new prescription for sumatriptan tablets to treat migraine headaches should report which of the following symptoms to the nurse?

A. Chew the tablet well before swallowing
B. Report swelling of the eyelids after dosage
C. Repeat dose in 1 hour for unrelieved headache
D. Take daily to prevent headaches

Correct answer: B

Rationale: The correct answer is B because swelling of the eyelids is a side effect of sumatriptan tablets that requires immediate reporting to the healthcare provider to prevent further complications. Choices A, C, and D are incorrect. Chewing the tablet well before swallowing is not necessary for sumatriptan tablets. Repeating the dose in 1 hour for unrelieved headache is incorrect as this medication should not be repeated within 24 hours. Taking sumatriptan daily for headache prevention is also incorrect as it is used for acute treatment, not prevention.

5. What is the priority intervention for a patient experiencing chest pain?

A. Administer nitroglycerin as prescribed.
B. Encourage the patient to take deep breaths.
C. Monitor the patient's blood pressure closely.
D. Encourage the patient to rest in a comfortable position.

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin as prescribed. Nitroglycerin helps relieve chest pain by dilating blood vessels and improving blood flow, addressing the immediate concern of chest pain. Encouraging deep breaths may not be appropriate for chest pain, monitoring blood pressure, although important, is not the priority when the patient is experiencing chest pain, and while resting in a comfortable position is beneficial, administering nitroglycerin is the priority intervention to address the chest pain.