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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Nursing Elites

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. Which factor places a patient at the highest risk for infection?

Correct answer: B

Rationale: The presence of chronic illness is the factor that places a patient at the highest risk for infection. Chronic illness can compromise the immune system's ability to fight off infections effectively, making individuals more susceptible to getting sick. Option A, a healthy immune system, actually reduces the risk of infection. Option C, being well-nourished, can support overall health but does not directly correlate with infection risk. While age over 65 years is a risk factor for certain infections due to age-related immune system changes, chronic illness has a more significant impact on infection risk.

3. A client has a new prescription for folic acid and believes it's only for pregnant women. What statement should the nurse make?

Correct answer: C

Rationale: The correct answer is C because folic acid is essential for the production of red blood cells in adults and children, not just for pregnant women. Option A is incorrect as folic acid is not exclusive to pregnant women. Option B is incorrect as a balanced diet may not provide sufficient folic acid. Option D is incorrect since folic acid supplementation is also recommended for other reasons beyond deficiency.

4. A nurse is caring for a client with a new colostomy. What is the nurse's responsibility regarding stoma care?

Correct answer: B

Rationale: The correct answer is to contact the stoma nurse to assist the client with care. Stoma nurses are specially trained to provide guidance on stoma care, especially for clients with new ostomies. Instructing the client to care for the stoma independently (Choice A) may not be appropriate initially as they may need professional guidance. Delegating the care of the stoma to a nursing assistant (Choice C) is not recommended as specialized care is required. Waiting until the next shift (Choice D) is not ideal as stoma care should not be delayed.

5. What are the key components of a pain assessment in a postoperative patient?

Correct answer: A

Rationale: The correct answer is A because in a postoperative patient, it is crucial to evaluate the effectiveness of the pain interventions that have been implemented. While choices B, C, and D are important aspects of a pain assessment, they do not specifically address the key component of assessing the effectiveness of the interventions applied postoperatively.

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