when inserting an indwelling urinary catheter in a female client and urine flows into the tubing what is the next action
Logo

Nursing Elites

HESI LPN

Adult Health 1 Final Exam

1. When inserting an indwelling urinary catheter in a female client and urine flows into the tubing, what is the next action?

Correct answer: D

Rationale: When urine flows into the tubing during the insertion of an indwelling urinary catheter, it confirms proper catheter placement. The next step should be to inflate the balloon with the specified amount of sterile water to secure the catheter in place. Documenting the color and clarity of the urine (choice A) is important for assessment but not the immediate next action. Inserting the catheter further (choice B) without securing it could cause harm. Asking the client to breathe deeply (choice C) is not relevant to this situation.

2. During a health screening, a client's blood pressure reads 160/100 mm Hg. What should the nurse recommend?

Correct answer: A

Rationale: A follow-up with a healthcare provider is necessary to assess and manage the newly identified hypertension. While dietary changes and exercise are important for managing high blood pressure, immediate lifestyle modifications without further evaluation by a healthcare provider may not be safe or effective. Option A is the most appropriate initial step to ensure proper assessment and management of the client's blood pressure. Therefore, choices B and C are incorrect in this scenario. Option D is also incorrect because not all options should be implemented without proper medical guidance.

3. The healthcare provider is assessing a client who has just undergone a thyroidectomy. Which assessment finding is most concerning?

Correct answer: C

Rationale: Tingling around the mouth is the most concerning finding as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common due to surgical manipulation, slight swelling at the incision site is expected postoperatively, and mild fever can be a normal inflammatory response. Hypocalcemia after thyroidectomy can lead to serious complications and should be addressed promptly to prevent further issues.

4. A client with a diagnosis of hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide?

Correct answer: C

Rationale: The most important information for the nurse to provide to a client with hypothyroidism being treated with levothyroxine is to report any symptoms of hyperthyroidism. Symptoms of hyperthyroidism, such as palpitations or tremors, may indicate overtreatment or excessive dosing of levothyroxine. Prompt reporting of these symptoms is crucial to prevent serious complications. Choices A and B are not the most critical information related to levothyroxine administration. Instructing the client to take the medication at bedtime or with food can be important for adherence but is not as crucial as monitoring for signs of hyperthyroidism. Choice D is incorrect as discontinuing the medication if feeling well can lead to a relapse of hypothyroidism symptoms.

5. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed fluoxetine (Prozac). What is the most important teaching point?

Correct answer: B

Rationale: The correct teaching point is to instruct the client to report any increase in suicidal thoughts. This is crucial because SSRIs like fluoxetine can initially increase suicidal ideation, especially at the beginning of treatment. Choice A is corrected to emphasize that fluoxetine can be taken with or without food. Choice C is unrelated as it pertains more to MAOIs than SSRIs like fluoxetine. Choice D is inaccurate as antidepressants like fluoxetine may take weeks to show significant improvement in symptoms, not within 24 hours.

Similar Questions

The nurse is caring for a client with cirrhosis of the liver. Which clinical finding is most concerning?
A client is being treated for heart failure. What should the nurse monitor to evaluate treatment effectiveness?
Which client is at the highest risk for developing pressure ulcers?
A client is being treated for dehydration. Which clinical finding would indicate that treatment is effective?
The nurse is caring for a client with a chest tube after thoracic surgery. What is the most important assessment related to the chest tube?

Access More Features

HESI LPN Basic
$69.99/ 30 days

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

HESI LPN Premium
$149.99/ 90 days

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

Other Courses