to assess the kidney function of a patient with an indwelling urinary foley catheter the nurse measures his hourly urine output she should notify the
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2024

1. To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures the hourly urine output. When should she notify the physician?

Correct answer: A

Rationale: Notifying the physician is necessary when the urine output is less than 30 ml/hour as it indicates impaired kidney function. Adequate urine output is essential for monitoring kidney function, and a urine output less than 30 ml/hour could suggest potential renal issues that require medical attention.

2. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?

Correct answer: A

Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.

3. During a seizure, what is the primary intervention?

Correct answer: A

Rationale: The primary intervention during a seizure is to protect the patient from injury. This involves creating a safe environment by moving harmful objects away, cushioning the head, and staying with the patient until the seizure ends. Inserting an airway is only necessary if the patient's airway is obstructed, not routinely during a seizure. Elevating the head of the bed is not a priority during an active seizure as it won't affect the seizure's outcome. Withdrawing all pain medications is not a standard practice unless there are specific contraindications related to the seizure itself.

4. A client is being instructed on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: D

Rationale: The correct answer demonstrates an understanding of the proper technique for using an incentive spirometer. Incentive spirometry helps to improve lung function by encouraging deep breathing and sustaining the inhalation to fully expand the lungs. Options A, B, and C are incorrect because they do not reflect the correct instructions for using an incentive spirometer.

5. For a rectal examination, the patient can be directed to assume which of the following positions?

Correct answer: B

Rationale: The correct position for a rectal examination is the Sims position, where the patient lies on their left side with the upper knee flexed. This position allows for easy access and visualization of the rectal area for examination.

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