a client who has a flaccid bladder is placed on a bladder training program which instruction should the nurse include in this clients teaching plan
Logo

Nursing Elites

HESI RN

HESI RN CAT Exit Exam

1. A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?

Correct answer: B

Rationale: The correct answer is B: Perform the Crede maneuver. The Crede maneuver is a technique used to manage a flaccid bladder by applying manual pressure over the bladder area to assist in the expulsion of urine. This technique helps promote bladder emptying. Choice A is incorrect because using manual pressure to express urine is not a standardized technique and may cause harm. Choice C is incorrect as applying an external urinary drainage device does not address the need for bladder training. Choice D is unrelated to bladder training for a flaccid bladder.

2. The nurse observes a client in a wheelchair with a vest restraint in place. What nursing intervention is most important for the nurse to implement?

Correct answer: A

Rationale: The correct answer is to assess the need for continued restraint. This is the most important nursing intervention as it ensures the client's safety and autonomy. Checking for urinary incontinence (Choice B) may be important but is not the priority in this situation. Determining skin integrity under the vest (Choice C) is essential but not as crucial as assessing the need for continued restraint. Performing range-of-motion exercises (Choice D) is important for client mobility but not the priority when a restraint is in place.

3. A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?

Correct answer: B

Rationale: The correct answer is B: 'It prevents the blood from clotting.' Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver, thereby preventing the formation of blood clots. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones from forming. Choice C is partially correct but not as specific as choice B in explaining how warfarin works. Choice D is unrelated to the mechanism of action of warfarin and is incorrect.

4. An angry client screams at the emergency department triage nurse, 'I've been waiting here for two hours! You and the staff are incompetent.' What is the best response for the nurse to make?

Correct answer: D

Rationale: The correct response for the nurse is to choose option D, 'I understand you are frustrated with the wait time.' This response acknowledges the client's emotions, shows empathy, and validates their feelings of frustration. Option A justifies the situation but does not address the client's emotional state. Option B is unfair to other patients and may not be based on urgency. Option C focuses on the nurse's actions rather than addressing the client's emotions, making it less effective than option D.

5. Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?

Correct answer: A

Rationale: The correct answer is A: Avoiding the administration of high levels of oxygen for extended periods. Oxygen toxicity can occur when high levels of oxygen are given for a prolonged period. It is important to monitor and adjust the oxygen levels as needed to prevent toxicity. Choice B is incorrect because administering a sedative to slow the respiratory rate does not directly prevent oxygen toxicity. Choice C is incorrect as removing the nasal cannula during the night can compromise the client's oxygenation. Choice D is incorrect as running oxygen through a hydration source does not prevent oxygen toxicity; instead, it may introduce risks associated with the hydration source.

Similar Questions

A client diagnosed with a deep vein thrombus (DVT) followed by a diagnosis of pulmonary embolism (PE) is receiving heparin via an infusion pump at a rate of 1400 u/hour. The client tells the nurse, 'I wish this medicine would hurry up and dissolve this clot in my lung so that I can go home'. What response is best for the nurse to provide?
A client is leaving the hospital against medical advice (AMA) and voluntarily signs the AMA form. Which nursing action is essential prior to the client leaving?
The nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?
The nurse assesses a client who is receiving an infusion of 5% dextrose in water with 20 mEq of potassium chloride. The client has oliguria and a serum potassium level of 6.5 mEq/L. What action should the nurse implement first?
The nurse is planning discharge teaching for a client with chronic kidney disease. Which information is most important for the nurse to provide this client?

Access More Features

HESI RN Basic
$89/ 30 days

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

HESI RN Premium
$149.99/ 90 days

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

Other Courses