a nurse is preparing to insert an indwelling urinary catheter for a client which of the following actions should the nurse take

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?

A. Insert the catheter 7.5 cm (3 in) into the urethra.
B. Insert the catheter until urine flow is established.
C. Cleanse the catheter with sterile water before insertion.
D. Insert the catheter 5 cm (2 in) into the urethra.

Correct answer: B

Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.

2. A healthcare professional is reviewing the medical record of a client who has a new prescription for enoxaparin. Which of the following findings should the healthcare professional report to the provider?

A. Platelet count 150,000/mm³
B. aPTT 30 seconds
C. Sodium 140 mEq/L
D. Serum creatinine 3.0 mg/dL

Correct answer: D

Rationale: An elevated serum creatinine level indicates impaired kidney function, which can affect the metabolism and excretion of enoxaparin, potentially leading to increased drug levels and risk of bleeding. Therefore, it is crucial to report a high serum creatinine level before administering enoxaparin. Platelet count, aPTT, and sodium levels are not directly related to the administration of enoxaparin and would not impact its use; hence, they do not need to be reported before starting the medication.

3. A nurse is planning care for a school-age child who is 4 hours postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?

A. Offer small amounts of clear liquids 6 hours following surgery.
B. Give cromolyn nebulizer solution every 6 hours.
C. Apply a warm compress to the operative site every 4 hours.
D. Administer analgesics on a scheduled basis for the first 24 hours.

Correct answer: D

Rationale: Administering analgesics on a scheduled basis for the first 24 hours is crucial in managing postoperative pain for the child. This helps control pain levels effectively, promoting comfort and aiding in the recovery process. Offering small amounts of clear liquids 6 hours following surgery may not be appropriate as the child may need time to recover from anesthesia. Giving cromolyn nebulizer solution every 6 hours is not indicated for postoperative care following appendicitis surgery. Applying a warm compress every 4 hours to the operative site may not be recommended as it can potentially interfere with the surgical wound healing process.

4. What is the first action to take for a patient experiencing a seizure?

A. Administer anticonvulsant medication
B. Protect the patient's head
C. Insert an oral airway
D. Restrain the patient

Correct answer: B

Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.

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

A. Administer aspirin
B. Administer nitroglycerin
C. Reposition the patient
D. Prepare for surgery

Correct answer: A

Rationale: The correct answer is to administer aspirin. Administering aspirin is a priority intervention for a patient presenting with chest pain because it helps reduce the risk of further clot formation and improves oxygenation. Aspirin is commonly used in the initial management of suspected cardiac chest pain. Administering nitroglycerin can follow aspirin administration to help with vasodilation. Repositioning the patient or preparing for surgery are not the primary interventions for chest pain presentation.