the nurse is caring for a client with a urinary catheter what is the most important intervention to prevent infection
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Nursing Elites

HESI LPN

Adult Health Exam 1 Chamberlain

1. When caring for a client with a urinary catheter, what is the most important intervention to prevent infection?

Correct answer: B

Rationale: The most important intervention to prevent infection when caring for a client with a urinary catheter is to ensure that the catheter bag is below the level of the bladder. This positioning helps prevent urine backflow, reducing the risk of infection. While using sterile technique for catheter care (Choice A) is important, ensuring proper drainage by keeping the catheter bag below the bladder is crucial to prevent infection. Providing perineal care daily (Choice C) is essential for hygiene but not directly related to preventing catheter-related infections. Changing the catheter only when necessary (Choice D) is important for maintenance, but correct positioning of the catheter bag is more critical in preventing immediate infection.

2. A client with heart failure is prescribed a low-sodium diet. The nurse notices the client's meal tray contains high-sodium foods. What action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to replace the high-sodium meal with a low-sodium option. This immediate intervention ensures that the client adheres to the prescribed low-sodium diet, crucial for managing heart failure and preventing fluid retention. Educating the client (Choice A) about the diet is important but not as urgent as ensuring they receive the correct meal. Reporting the error to the dietary department (Choice C) can be done after addressing the immediate issue. Encouraging the client to avoid high-sodium foods (Choice D) is not as effective as replacing the current meal with a suitable alternative.

3. The nurse is assessing a client with congestive heart failure who is receiving furosemide (Lasix). Which laboratory value should the nurse monitor closely?

Correct answer: B

Rationale: The correct answer is B: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring the potassium level is crucial to prevent complications such as cardiac arrhythmias. Sodium level (choice A) is not typically affected by furosemide. Calcium level (choice C) and chloride level (choice D) are also not the primary focus of monitoring when a client is on furosemide for heart failure.

4. Which nonfood item is the most common cause of respiratory arrest in young children?

Correct answer: D

Rationale: The correct answer is D, Latex balloons. Latex balloons can pose a significant choking hazard to young children if inhaled, potentially leading to respiratory arrest. Broken rattles, buttons, and pacifiers are not typically known to cause respiratory arrest in young children. While these items can present choking hazards as well, the most common cause of respiratory arrest among young children is due to inhaling latex balloons.

5. A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed oxygen therapy at 2 liters per minute via nasal cannula. What is the most important instruction the nurse should provide?

Correct answer: C

Rationale: The most important instruction the nurse should provide to a client with COPD prescribed oxygen therapy is not to adjust the oxygen flow rate without consulting a healthcare provider. This is crucial because too much oxygen can suppress the client's respiratory drive, leading to further complications. Choice A is incorrect because increasing the oxygen flow rate without medical advice can be harmful. Choice B is incorrect as oxygen therapy should be used as prescribed, not just when symptoms occur. Choice D is incorrect as the priority is to ensure the correct oxygen flow rate rather than using a humidifier.

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