a nurse is using an open irrigation technique to irrigate a clients indwelling urinary catheter which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Leadership Practice B

1. When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?

Correct answer: B

Rationale: When irrigating an indwelling urinary catheter, the nurse should use a 20-mL syringe for the procedure. This syringe size helps to provide adequate pressure for effective irrigation. Placing the client in a side-lying position is not necessary for this procedure. Instilling a specific amount of irrigation fluid into the catheter is not mentioned in the scenario. Subtracting the amount of irrigant used from the client's urine output is not a standard practice in catheter irrigation.

2. Which of the following are essential components of strategic planning?

Correct answer: D

Rationale: In strategic planning, values and vision and mission statements play crucial roles. Values guide the organization's culture and decision-making processes, while vision and mission statements outline its long-term goals and purpose. Reengineering, on the other hand, is a separate process focused on restructuring business processes for improved performance efficiency. Therefore, the correct components of strategic planning are values and vision and mission statements, making option D the correct answer. Choices A and B are correct because they are directly related to setting the direction and purpose of the organization in a strategic planning process, while choice C, reengineering, is not typically considered a core element of strategic planning.

3. While caring for a client with tuberculosis, which of the following actions should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take when caring for a client with tuberculosis is to use antimicrobial sanitizer for hand hygiene. Tuberculosis is primarily spread through the air, so wearing a surgical mask when providing care (choice B) would be more appropriate for diseases transmitted via droplets. Limiting visitors (choice C) and wearing gloves for oral care (choice D) are important infection control measures but are not specifically tailored to tuberculosis transmission.

4. One of the most useful tools to determine reasons for turnover is:

Correct answer: B

Rationale: Surveys are one of the most effective tools to determine reasons for turnover because they allow employees to provide feedback anonymously, leading to more truthful responses. While questioning can be part of the process, surveys provide a structured and standardized way to collect data. Employee forums may not always elicit honest responses due to peer pressure or fear of repercussions. Telephone calls may not reach all employees and do not guarantee anonymity, potentially leading to biased or incomplete information.

5. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hour. Which of the following actions should the nurse take next?

Correct answer: D

Rationale: In this scenario, the nurse should notify the nursing manager next. The surgeon's instructions are related to the client's condition, and it is crucial to inform the nursing manager about the situation. Option A is incorrect because documenting the surgeon's instructions in the medical record is not the immediate next step. Option B is also incorrect as completing an incident report is not warranted in this situation. Option C is not the best choice as consulting the charge nurse may cause a delay in escalating the situation to higher management, which is necessary in cases of emergency like hemorrhagic shock.

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