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

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?

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. A nurse manager is presenting to a group of unit nurses the categories regulated under the Controlled Substances Act. Which of the following medications should the nurse include under Schedule II?

Correct answer: B

Rationale: The correct answer is B: Hydrocodone bitartrate. According to the Controlled Substances Act, hydrocodone bitartrate is classified as a Schedule II controlled substance due to its high potential for abuse and addiction. Diazepam (Choice C) and morphine (Choice D) are classified as Schedule IV and Schedule II controlled substances, respectively. Buprenorphine hydrochloride (Choice A) is classified as a Schedule III controlled substance. Therefore, hydrocodone bitartrate should be included under Schedule II medications when discussing the categories regulated under the Controlled Substances Act.

3. A client has bilateral eye patches following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

Correct answer: D

Rationale: Describing the location of food on the tray helps promote independence for the client with bilateral eye patches. By providing clear instructions on where the food is placed, the client can independently locate and consume their meal. Option A is incorrect as physically placing the client's hands on the tray does not encourage independence. Option B is unnecessary unless there are specific dietary restrictions indicated. Option C does not promote the client's independence and should be avoided unless absolutely necessary.

4. A client is being taught about which foods to include in a low fiber diet. Which statement indicates understanding?

Correct answer: C

Rationale: The correct answer is C because white rice is a low-fiber food suitable for a low-fiber diet, making it an appropriate choice. Choices A, B, and D are incorrect because fresh pear, refried beans, and bran cereal are high-fiber foods and not suitable for a low-fiber diet.

5. Which nursing action will best help a patient with diabetes manage their condition?

Correct answer: C

Rationale: The correct answer is C: Teach the patient how to administer insulin. This action is crucial in promoting self-management and control of diabetes. By educating the patient on administering insulin, they can actively participate in their treatment plan. Monitoring blood sugar levels (choice A) is important but doesn't empower the patient to take direct action. Encouraging a diabetic meal plan (choice B) is beneficial but may not directly address the need for insulin administration. Teaching about the complications of diabetes (choice D) is essential but may not be as immediately impactful as teaching insulin administration for day-to-day management.

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