a nurse is caring for a client who has an indwelling urinary catheter what should the nurse identify as a catheter occlusion a nurse is caring for a client who has an indwelling urinary catheter what should the nurse identify as a catheter occlusion
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a catheter occlusion?

Correct answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention indicates that the bladder is full and there is impaired elimination, which could be caused by catheter occlusion. Pain during urination (choice A) is not typically associated with catheter occlusion but may indicate a urinary tract infection. Cloudy urine (choice C) can be a sign of infection but is not specific to catheter occlusion. Blood in the catheter tube (choice D) may indicate trauma during catheter insertion but is not a typical finding in catheter occlusion.

2. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication in the abdomen subcutaneously. This route ensures proper absorption of the medication. Aspiration is not necessary before injecting enoxaparin as it is a subcutaneous injection, not an intramuscular injection. Massaging the site after injecting should be avoided to prevent bruising. Enoxaparin injections are typically given at a 45 to 90-degree angle, not necessarily at a strict 90-degree angle.

3. To form a core support group of nurses, where should the nurse organizer conduct meetings to gather initial information?

Correct answer: B

Rationale: The correct approach is to conduct meetings in homes or local businesses with staff nurses. This location ensures confidentiality, prevents management influence, and allows the focus to be on gathering support for forming a core support group. Choice A is incorrect as involving managers may compromise the independence and authenticity of the group. Choice C is incorrect as conducting meetings at the facility may not provide a secure and unbiased environment for open discussions. Choice D is incorrect because holding meetings at the work site with respected leaders may lead to biased opinions and hinder open communication.

4. A client is being taught by a nurse how to ascend stairs while using crutches. Which of the following actions should the nurse instruct the client to take first?

Correct answer: B

Rationale: The correct answer is to instruct the client to step up with the unaffected leg first. This action is crucial as it ensures proper balance and safety when ascending stairs with crutches. By stepping up with the unaffected leg first, the client can maintain stability and reduce the risk of falls. Choices A, C, and D are incorrect. Moving both crutches up first (Choice A) may lead to imbalance and difficulty in weight distribution. Leaning forward on the crutches before stepping up (Choice C) can compromise the client's stability and increase the risk of falling. While holding onto the handrail for support (Choice D) is important, stepping up with the unaffected leg first takes precedence to establish a secure and safe movement up the stairs.

5. A nurse is reading a journal article about life expectancy and various cultural groups. The article describes statistics, stating that a baby born to a black American couple has a life expectancy lower than that of a baby born to a white American couple. The article goes on to describe the life expectancy as the babies get older. Which finding would the nurse most likely identify as reflecting the life expectancy of the baby born to the black American couple by the seventh decade?

Correct answer: A

Rationale: Historically, black Americans have experienced a lower standard of living and less access to health care than their white counterparts, leading to a lower life expectancy. However, by the seventh decade of life, survival rates for black individuals begin to equal that of similarly aged white individuals. Choice B is incorrect as it indicates a higher life expectancy for black individuals, which is not supported by the information provided. Choice C is incorrect as it suggests a drastic decrease in life expectancy for black individuals, which is not in line with the trend described. Choice D is incorrect as it implies a temporary increase in life expectancy for black individuals until age 75, which is not supported by the information that survival rates begin to equal by the seventh decade.

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