a nurse is caring for a client who is struggling to void after having an indwelling catheter removed what action should the nurse take a nurse is caring for a client who is struggling to void after having an indwelling catheter removed what action should the nurse take
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023 Quizlet

1. What action should the nurse take for a client struggling to void after having an indwelling catheter removed?

Correct answer: C

Rationale: The correct action for the nurse to take is to pour warm water over the client's perineum. This intervention helps stimulate urination after catheter removal by providing warmth and promoting relaxation of the muscles. Assessing for bladder distention after 2 hours (Choice A) is not the initial intervention to facilitate voiding. Encouraging the client to try urinating in a sitting position (Choice B) may be uncomfortable if the client is struggling to void. Restricting the client's fluid intake (Choice D) is not appropriate as it can further exacerbate the issue by concentrating the urine.

2. When assessing a client with a small bowel obstruction, what finding should a nurse expect?

Correct answer: C

Rationale: High-pitched bowel sounds are often heard early in a small bowel obstruction due to increased peristalsis as the bowel tries to overcome the blockage. Choices A, B, and D are incorrect. Abdominal distention is more commonly associated with large bowel obstructions, while large bowel movements and copious vomiting are not typical findings in small bowel obstructions.

3. What is the process for taking a telephone order from a provider?

Correct answer: B

Rationale: The correct process for taking a telephone order from a provider involves reading back the information for accuracy. This step ensures that the order is correctly understood and reduces the risk of errors. While listing patient information (Choice A) is essential, it does not encompass the complete process of verifying the order. Having a witness listen to the order (Choice C) may not always be practical or necessary, as direct verification is more efficient. Writing down the order and following up (Choice D) is not as crucial as the immediate read-back process, which allows for real-time clarification and confirmation.

4. What is the interval between tetanus toxoid doses for pregnant women?

Correct answer: A

Rationale: The correct interval between doses of tetanus toxoid for pregnant women is 4 weeks. This interval ensures that pregnant women receive adequate protection against tetanus, particularly in areas where the disease is prevalent. The 4-week interval helps in building and maintaining immunity to protect both the pregnant woman and her developing baby from tetanus infection.

5. When teaching about community preparedness for a community group, the nurse should explain that the components of the national disaster medical system (NDMS) provide assistance in what form? Select all that apply.

Correct answer: B, C

Rationale: The correct answers are B and C. The NDMS is designed to provide medical response during disasters, assist in patient movement, and offer definitive care to disaster victims. This includes organizing teams of healthcare providers with specialized skills and equipment to respond effectively to emergencies. Patient evacuation from disaster areas to safer locations is also a key function of the NDMS to ensure the well-being of those affected by the disaster. Options A and D are incorrect because the NDMS does not provide bomb disposal services and is primarily focused on medical response rather than mental health care.

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