a nurse is caring for a client who has an indwelling urinary catheter what finding indicates a catheter occlusion
Logo

Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates a catheter occlusion?

Correct answer: A

Rationale: Bladder distention is the correct finding that indicates a catheter occlusion. When the catheter is occluded, urine cannot drain properly, leading to the build-up of urine in the bladder, causing distention. Bladder spasms (Choice B) are not typically associated with catheter occlusion but may indicate irritation or infection. Hematuria (Choice C) refers to blood in the urine and is not specific to catheter occlusion. Increased urine output (Choice D) is not indicative of catheter occlusion but may suggest other conditions like diabetes insipidus.

2. A nurse is teaching a client about ways to reduce the risk of deep vein thrombosis (DVT) after surgery. What should the nurse include in the teaching?

Correct answer: B

Rationale: The correct answer is to 'Use sequential compression devices.' Sequential compression devices help prevent DVT by promoting venous return, reducing stasis in the veins, and preventing blood clot formation. Resting in bed for long periods (Choice A) can actually increase the risk of DVT due to decreased mobility. Avoiding leg exercises (Choice C) is also not recommended as mobilization and exercises can help prevent blood clots. Keeping legs crossed (Choice D) can impede blood flow and is not advisable in reducing the risk of DVT.

3. A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?

Correct answer: C

Rationale: The correct answer is C: 'Use a special mattress to reduce pressure on the skin.' This intervention is crucial in preventing skin breakdown in clients with limited mobility as it helps to reduce pressure on bony prominences. Repositioning every 4 hours (Choice A) is important but may not be sufficient to prevent skin breakdown entirely. Applying lotion every 2 hours (Choice B) may not address the root cause of skin breakdown related to pressure. Increasing fluid intake (Choice D) is beneficial for overall skin health but may not directly prevent skin breakdown caused by pressure points.

4. A nurse is monitoring a client who is receiving continuous enteral feedings. What finding suggests the client is not tolerating the feeding?

Correct answer: B

Rationale: Nausea is a common sign indicating that the client is not tolerating enteral feedings well. It can be a result of various issues such as feeding intolerance, infection, or other underlying conditions. Nausea should be promptly addressed to prevent further complications. Increased bowel sounds (Choice A) are not typically indicative of feeding intolerance. Elevated blood pressure (Choice C) and fever (Choice D) are generally not directly related to enteral feeding intolerance unless there are specific underlying conditions contributing to them.

5. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. Which food should the nurse instruct the client to avoid?

Correct answer: B

Rationale: Correct! Orange slices should be avoided by clients on a mechanical soft diet as they can be difficult to chew and swallow. Steamed carrots, mashed potatoes, and baked chicken are suitable choices for a mechanical soft diet, as they are softer in texture and easier to consume without posing a risk of choking or swallowing difficulties.

Similar Questions

A nurse is preparing to administer medications to a client through a nasogastric (NG) tube. Which action should the nurse take?
A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skill should the nurse expect?
A nurse is assessing a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?
A client with diabetes mellitus is being taught about foot care by a nurse. Which statement indicates understanding?
A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?

Access More Features

ATI RN Basic
$69.99/ 30 days

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

ATI RN Premium
$149.99/ 90 days

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

Other Courses