an assistive personnel ap is assisting a nurse with the care of a female client who has an indwelling urinary catheter which of the following actions
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HESI LPN

Practice HESI Fundamentals Exam

1. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching?

Correct answer: A

Rationale: Hanging the collection bag below the level of the bladder is the correct technique for maintaining proper drainage and preventing backflow in a client with an indwelling urinary catheter. Therefore, choice A is the correct answer as it indicates a need for further teaching. Choices B, C, and D demonstrate appropriate actions in catheter care. Performing hand hygiene before handling the catheter helps prevent infection, securing the catheter to the client’s leg with tape prevents accidental dislodgement, and emptying the collection bag when it is full ensures that the catheter functions effectively.

2. What is the most important action for the LPN/LVN to take to prevent infection in a client with an indwelling urinary catheter?

Correct answer: A

Rationale: The most crucial action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This step helps prevent obstruction in the tubing, maintaining proper urine flow and reducing the risk of infection. Changing the catheter every 72 hours is not recommended unless clinically indicated, as routine changes can increase the risk of introducing pathogens. Cleaning the perineal area with an antiseptic solution is essential for general hygiene but does not directly prevent catheter-related infections. Irrigating the catheter with normal saline every shift is not a standard practice and can introduce microorganisms into the urinary tract, increasing the risk of infection.

3. A healthcare professional is preparing information for a change-of-shift report. Which of the following information should the healthcare professional include in the report?

Correct answer: D

Rationale: During a change-of-shift report, healthcare professionals should include the medication regimen from the medication administration record. This information ensures continuity of care and helps incoming staff understand the patient's medication needs and schedule. While input and output measurements, blood pressure readings, and scheduled procedures like a bone scan are important aspects of patient care, they may not be immediately relevant for the incoming shift. Focusing on medication details helps prevent errors and ensures the patient receives the correct medications at the right times.

4. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?

Correct answer: B

Rationale: The correct answer is B: 'During the inhalation.' Administering the medication while inhaling ensures proper delivery to the lungs. Inhaling the medication allows it to reach the lungs effectively for optimal therapeutic benefit. Choices A, C, and D are incorrect because administering the medication after exhalation or at the end of inhalations may result in improper drug delivery and reduced therapeutic effects.

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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