the nurse is caring for a client with an indwelling urinary catheter what is the most important action to prevent catheter associated urinary tract in
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Nursing Elites

HESI LPN

Adult Health 2 Exam 1

1. The nurse is caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?

Correct answer: A

Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.

2. The nurse is assessing a client with a suspected diagnosis of deep vein thrombosis (DVT). Which clinical sign is most indicative of DVT?

Correct answer: A

Rationale: Corrected Rationale: Redness and warmth over the affected area are classic signs of inflammation, which commonly occur in deep vein thrombosis (DVT) due to the obstruction of blood flow. These symptoms result from the body's inflammatory response to the blood clot. Choices B, C, and D are less indicative of DVT. Decreased peripheral pulses may occur in arterial insufficiency rather than DVT. Cyanosis of the toes indicates decreased oxygenation and is more characteristic of arterial issues. Muscle cramps in the calf are nonspecific and can be caused by various conditions, not solely DVT.

3. The healthcare provider is assessing a client with a suspected diagnosis of appendicitis. Which symptom is most indicative of this condition?

Correct answer: C

Rationale: Rebound tenderness at McBurney's point is a classic sign of appendicitis. This symptom is due to irritation of the peritoneum when pressure is released during palpation. Right upper quadrant pain (Choice A) is more commonly associated with gallbladder issues. Nausea and vomiting (Choice B) can occur in various abdominal conditions and are not specific to appendicitis. Hematuria (Choice D) is the presence of blood in the urine and is not a typical symptom of appendicitis.

4. A client with a diagnosis of pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

Correct answer: B

Rationale: Encouraging increased fluid intake is the appropriate intervention to assist the client with pneumonia who is having difficulty expectorating thick secretions. Adequate hydration helps to thin the secretions, making them easier to cough up. Administering antibiotics (Choice A) is important for treating the infection itself but does not directly address the thick secretions. Chest physiotherapy (Choice C) may be beneficial in some cases but is not the initial intervention for thick secretions. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

5. The client with high blood pressure is being taught by the nurse to avoid adding salt during cooking. What effect does sodium have on blood pressure?

Correct answer: C

Rationale: The correct answer is C: 'It causes vasoconstriction of the blood vessels.' Sodium can lead to vasoconstriction, which narrows the blood vessels, increasing resistance to blood flow and subsequently raising blood pressure. Choices A, B, and D are incorrect. Sodium does not decrease blood viscosity, but it can lead to fluid retention, which increases blood volume and pressure. It does not enhance the excretion of potassium; instead, high sodium intake can lead to potassium excretion by the kidneys.

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