urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours the nurse inserts the catheter but no
Logo

Nursing Elites

HESI RN

HESI Fundamentals

1. Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?

Correct answer: C

Rationale: In this scenario, if no urine is seen in the tubing after inserting the catheter, it is likely that the catheter is in the vagina rather than the bladder. Leaving the first catheter in place will help locate the meatus more easily when attempting the second catheterization. This approach ensures correct placement of the catheter in the bladder and minimizes the risk of causing unnecessary discomfort or trauma to the patient.

2. The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?

Correct answer: A

Rationale: To protect client privacy on social media, it is essential to remove any identifying information of clients who participated in the project. This ensures that sensitive information is not disclosed without consent and maintains confidentiality. Choice B is incorrect because while authored content may be legally discoverable, it does not directly relate to protecting client privacy on social media. Choice C is incorrect as it pertains to the credibility of sources, not client privacy. Choice D is also incorrect as it focuses on copyright laws rather than client privacy protection.

3. The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?

Correct answer: A

Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.

4. The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?

Correct answer: D

Rationale: When providing passive ROM exercises to the hip and knee for an unconscious client, it is essential to support the joints of the knee and ankle. The next action should be to cradle the client's heel and gently move the limb in a slow, smooth, firm, but gentle manner. This helps maintain joint mobility and prevent contractures.

5. When faced with caring for a close friend in a professional setting, which action should the staff member take first?

Correct answer: B

Rationale: When faced with caring for a close friend in a professional setting, the staff member should first explain the relationship to the charge nurse and ask for reassignment. This is important to maintain professional boundaries, prevent conflicts of interest, and ensure that the care provided is unbiased and without compromising the friend's confidentiality. Choice A is incorrect because the priority should be on professional boundaries rather than informing the friend about confidentiality. Choice C is not appropriate as it puts the burden on the client to address any discomfort. Choice D is incorrect as accepting the assignment without addressing the potential conflict of interest could lead to compromised care.

Similar Questions

A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?
The healthcare provider selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the healthcare provider use to identify placement of the IV access?
The census on the unit is 90 percent, and there are no private rooms available. An elderly client with influenza is admitted. Which of the following rooms would it be appropriate to assign this client?
When caring for a client in hemorrhagic shock, how should the nurse position the client?
A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses