a nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter which of the following actions s a nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter which of the following actions s
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ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: Performing a bladder scan is the first step to assess bladder retention before any further interventions.

2. A teen with asthma asks the nurse why it is hard to breathe during an asthma attack. The nurse explains that exposure to a “trigger” results in which of these manifestations?

Correct answer: D

Rationale: The correct answer is D. Asthma triggers cause bronchoconstriction, airway inflammation, and increased mucus production, leading to difficulty breathing. This combination of manifestations results in narrowing of the airways, making it hard for the individual to breathe effectively. Choices A, B, and C are incorrect because during an asthma attack, bronchodilation, muscle relaxation, and decreased mucus production do not occur. Instead, the airways constrict, become inflamed, and produce excess mucus, contributing to the breathing difficulties experienced by individuals with asthma.

3. What health teaching would not help an older adult avoid a musculoskeletal injury?

Correct answer: A

Rationale: Avoiding home modifications can increase the risk of falls and injuries in older adults.

4. The predominant characteristic of the intellectual development of a child aged 2 to 7 years is egocentricity. Which of the following best describes this concept?

Correct answer: B

Rationale: Egocentricity in children aged 2 to 7 years means they are unable to see things from another person's perspective. This characteristic is a normal part of their cognitive development during this stage. Choice A, 'Selfishness,' is not an accurate description as egocentricity is more about a limited ability to understand others' viewpoints rather than intentional selfishness. Choice C, 'Able to put self in another’s place,' is incorrect as egocentric children struggle to do this. Choice D, 'Prefers to play alone,' is not directly related to egocentricity but may be a behavior exhibited by some children for various reasons.

5. A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam

Correct answer: B

Rationale: The correct answer is 'B' - as soon as possible. Patients with type 2 diabetes should have a dilated eye exam shortly after diagnosis to check for any signs of diabetic retinopathy, a common complication of diabetes. Waiting for 2 years (choice A) may lead to missing early signs of eye damage. Choice C is incorrect as there is no specific age requirement mentioned for the eye exam. Choice D is also incorrect because early detection and intervention are crucial in diabetic eye disease.

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