A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

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RN ATI Capstone Proctored Comprehensive Assessment 2019 B Questions

Question 1 of 5

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: The correct action for the nurse to take is to withdraw 3 to 5 ml of urine from the port for an accurate culture and sensitivity test. Wiping the area around the needleless port with sterile water (Choice A) is not necessary when obtaining a urine specimen. Inserting the syringe into the needleless port at a 60-degree angle (Choice B) is incorrect as it does not align with the correct procedure for obtaining a urine specimen. Donning sterile gloves (Choice D) is a good practice but not the immediate action required for obtaining a urine specimen.

Question 2 of 5

A client has bilateral eye patches following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

Correct Answer: D

Rationale: Describing the location of food on the tray helps promote independence for the client with bilateral eye patches. By providing clear instructions on where the food is placed, the client can independently locate and consume their meal. Option A is incorrect as physically placing the client's hands on the tray does not encourage independence. Option B is unnecessary unless there are specific dietary restrictions indicated. Option C does not promote the client's independence and should be avoided unless absolutely necessary.

Question 3 of 5

A client has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

Correct Answer: C

Rationale: The correct answer is C. When instructing a client who is prescribed clopidogrel, the nurse should include information about stopping the medication 5 days before any planned surgeries to reduce the risk of bleeding. This is crucial to prevent excessive bleeding during surgical procedures. Choices A, B, and D are incorrect because taking the medication with food, the frequency of administration, and the possibility of black-colored stools are not specific instructions related to clopidogrel use.

Question 4 of 5

A client had a left hip arthroplasty. Which of the following interventions should the nurse use to prevent dislocation?

Correct Answer: A

Rationale: The correct answer is to maintain a foam wedge between the legs. This intervention helps prevent hip dislocation by maintaining proper leg alignment after surgery. Monitoring for shortening of the affected leg (choice B) is not directly related to preventing dislocation. Encouraging the use of elastic stockings (choice C) is more related to preventing deep vein thrombosis rather than dislocation. Avoiding flexing the hips more than 60 degrees (choice D) is important post-surgery, but it is not the most direct intervention to prevent dislocation.

Question 5 of 5

A client who has a new prescription for ferrous sulfate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer: A

Rationale: The correct answer is A. When taking ferrous sulfate, dark tarry stools can occur as a common side effect due to the iron content in the medication. This is a normal response to the medication and not a cause for concern. Choices B, C, and D are incorrect because increased bruising, reduced infections, and amber-colored urine are not expected side effects of ferrous sulfate.

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