a nurse is using an open irrigation technique to irrigate a clients indwelling urinary catheter which of the following actions should the nurse take
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Nursing Elites

HESI LPN

HESI Fundamental Practice Exam

1. When using an open irrigation technique to irrigate a client's indwelling urinary catheter, which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take when using an open irrigation technique on a client with an indwelling urinary catheter is to subtract the amount of irrigant used from the client's urine output. This calculation helps ensure an accurate measurement of the client's actual urine output by accounting for the irrigation fluid introduced into the catheter. Placing the client in a side-lying position (Choice A) is not directly related to the irrigation procedure. Instilling a specific volume of irrigation fluid (Choice B) may vary depending on the client's condition and the healthcare provider's order. Using a 20 mL syringe for irrigation (Choice D) is a matter of equipment choice and does not directly impact the calculation of urine output in this context.

2. A middle adult client tells the nurse, 'I feel so useless now that my children do not need me anymore.' Which of the following responses should the nurse make?

Correct answer: A

Rationale: The correct response is A. Middle adulthood is a stage where individuals often experience generativity, finding fulfillment in guiding and nurturing others. By acknowledging this aspect, the nurse can help the client explore opportunities to engage in activities that provide a sense of purpose and satisfaction. Choice A validates the client's feelings and offers a constructive way to address them. Choices B, C, and D do not address the client's emotional need for purpose and may not encourage the client to seek meaningful ways to address their feelings of uselessness.

3. To use the nursing process correctly, what must the nurse do first?

Correct answer: A

Rationale: The first step in the nursing process is to obtain information about the client. This step involves gathering data through assessment to understand the client's needs, health status, and preferences. Developing a care plan (Choice B) comes after the assessment phase. Implementing interventions (Choice C) and evaluating client outcomes (Choice D) occur in subsequent stages of the nursing process. Therefore, the correct initial step is to gather information about the client to form a foundation for providing individualized care.

4. A client is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

Correct answer: C

Rationale: The correct answer is C: “This test will provide information about the function of your liver.” Alanine aminotransferase (ALT) is an enzyme mainly found in the liver. An elevated ALT level may indicate liver damage or disease. Choices A, B, and D are incorrect because ALT is specifically related to liver function and not indicative of blood clot risk, heart performance, or kidney function.

5. The LPN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

Correct answer: B

Rationale: Reassessing the client's blood pressure using a larger cuff is the most important action for the nurse to implement in this situation. Using the correct cuff size is crucial for obtaining accurate blood pressure readings. By reassessing with a larger cuff, the nurse can ensure an accurate measurement and proper monitoring of the client's blood pressure. Choice A is not the best option as it doesn't address the immediate need for accurate blood pressure measurement. Choice C is not the most appropriate action at this time since the immediate concern is ensuring correct blood pressure assessment. Choice D, while important, is not the most critical step in this scenario where immediate reassessment is needed with the correct cuff size.

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