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

ATI RN

ATI Leadership Practice B

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

A. Position the client in a side-lying position.
B. Perform the irrigation using a 20-mL syringe.
C. Instill 15 mL of irrigation fluid into the catheter with each flush.
D. Measure and record the amount of irrigant used.

Correct answer: B

Rationale: When irrigating an indwelling urinary catheter, the nurse should use a 20-mL syringe for the procedure. This syringe size helps to provide adequate pressure for effective irrigation. Placing the client in a side-lying position is not necessary for this procedure. Instilling a specific amount of irrigation fluid into the catheter is not mentioned in the scenario. Subtracting the amount of irrigant used from the client's urine output is not a standard practice in catheter irrigation.

2. Who is the best person to describe the job to an applicant?

A. Previous employee
B. Human resource manager
C. Nursing manager
D. Chief operating officer

Correct answer: C

Rationale: The nursing manager is the most suitable person to describe the job to an applicant because they are directly involved in the day-to-day operations and requirements of the position. They have firsthand knowledge of the job responsibilities, expectations, and qualifications needed. Human resource managers are involved in recruitment but may not have the detailed operational knowledge that a nursing manager possesses. A previous employee may provide insights into the work environment but may not have a comprehensive understanding of the current job requirements. The chief operating officer oversees the organization's overall operations and strategy, so they may not have the specific details about the job to effectively describe it to an applicant.

3. What behaviors can be observed before a person becomes violent? (EXCEPT)

A. Wandering
B. Tense shoulders and clenched fists
C. Blank stare
D. Positioned with one foot in back and an arm pulled back

Correct answer: A

Rationale: Before a person becomes violent, observable behaviors may include tense shoulders, clenched fists, a blank stare, and being positioned with one foot in back and an arm pulled back. Wandering is not typically associated with threatening behaviors signaling imminent violence. DelBel (2003) suggests that strategies such as relaxed body language, maintaining physical distance, and silence can help de-escalate an agitated individual's response.

4. After receiving change-of-shift report, which patient should the nurse assess first?

A. 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12%
B. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL
C. 40-year-old who is pregnant and has an oral glucose tolerance test result of 202 mg/dL
D. 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain

Correct answer: B

Rationale: The correct answer is B because the patient with a blood glucose level of 40 mg/dL (hypoglycemia) needs immediate attention. Hypoglycemia is an emergency situation that requires prompt intervention to prevent adverse effects such as seizures or loss of consciousness. Assessing and managing this patient first is crucial to prevent further deterioration. Choices A, C, and D do not present immediate life-threatening situations requiring urgent intervention like severe hypoglycemia does. While a high hemoglobin A1C level (choice A), an abnormal oral glucose tolerance test result (choice C), and acute abdominal pain (choice D) are important issues, they do not pose an immediate threat to the patient's life compared to severe hypoglycemia.

5. How has advanced technology in health care, such as integrated health records, benefited nurses?

A. Skip the assessment step of the nursing process
B. Order medications
C. Take blood samples
D. Track patients' vital signs

Correct answer: D

Rationale: Advanced technology in health care, like integrated health records, has enabled nurses to efficiently track patients' vital signs. This capability helps nurses monitor patients' health status closely and make informed decisions regarding their care. Choices A, B, and C are incorrect because technology does not replace the vital role of nurses in conducting assessments, ordering medications (typically done by prescribers), or collecting blood samples.