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. The nurse is providing care for a client who is receiving total parenteral nutrition (TPN). Which laboratory value should the nurse monitor closely to assess for complications?

Correct answer: B

Rationale: The correct answer is B: Blood glucose. When caring for a client receiving total parenteral nutrition (TPN), monitoring blood glucose levels is essential due to the increased risk of hyperglycemia associated with TPN infusion. Elevated blood glucose levels can lead to complications such as hyperglycemia, which can be harmful to the client. While monitoring serum potassium (Choice A), serum sodium (Choice C), and serum calcium (Choice D) are also important aspects of care, when specifically considering TPN administration, blood glucose monitoring takes precedence due to the potential for significant complications related to glucose imbalances.

3. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

Correct answer: A

Rationale: The correct answer is A. Washing out the feeding bag with warm water once every 24 hours is not sufficient to prevent bacterial growth and can lead to diarrhea. Using hot water may damage the feeding bag. Washing out the feeding bag with soap and water every 24 hours is excessive and may leave residue that could be harmful. Changing the feeding bag every 24 hours is important for preventing infections but does not directly address the issue of diarrhea in this case.

4. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Auscultating the abdomen before palpation is the correct action for the nurse to take in this scenario. This approach helps to assess bowel sounds accurately and prevents the alteration of bowel sounds that can occur due to palpation. By auscultating first, the nurse can gather important information about bowel function before proceeding with the palpation. Choice A is incorrect because deep palpation should be avoided initially, especially in a client reporting abdominal pain, as it may cause discomfort or potential harm. Choice C is incorrect as palpation should typically start away from the site of pain to prevent exacerbating discomfort. Choice D is incorrect because assessing bowel sounds with the bell of the stethoscope is not the initial step recommended when a client reports abdominal pain; auscultation should be performed with the diaphragm of the stethoscope first.

5. A nurse is assigned to a manipulative client for 5 days and becomes aware of feelings of reluctance to interact with the client. What should the nurse do next?

Correct answer: A

Rationale: It is important for the nurse to address their feelings of reluctance when dealing with a manipulative client by discussing them with an objective peer or supervisor. This action can provide valuable insight and support for managing the nurse-client relationship. Choice B should be avoided as limiting contacts with the client may not address the underlying issues and could potentially harm the therapeutic relationship. Choice C is confrontational and may escalate the situation rather than resolve it. Choice D, while important, should come after addressing the nurse's feelings and seeking support.

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