A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

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Fundamentals of Nursing Oxygenation NCLEX Questions Questions

Question 1 of 5

A nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: Subtract the amount of irrigant used from the client's urine output. The client should be supine or dorsal recumbent for maximum access, the open irrigation requires 30-40 ml of fluid, and the nurse will need a 30-50 ml syringe to perform the irrigation.

Question 2 of 5

The nurse is assessing a client who has required bed rest for the past month. Which of the following findings should the nurse identify as an indication that the client has developed thrombophlebitis?

Correct Answer: C

Rationale: Calf swelling. Bladder distention is from urinary retention, bed rest can cause postural hypotension, and a decrease in bowel sounds is a sign of peristalsis which can lead to constipation.

Question 3 of 5

A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?

Correct Answer: B

Rationale: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. The nurse should regulate the flow by aligning the middle of the ball, the reservoir bag of a partial rebreather should inflate one third to one half, and only use water-soluble lubricant to protect the client's skin.

Question 4 of 5

A nurse is admitting a new client. Which of the following actions should the nurse take while performing medication reconciliation?

Correct Answer: C

Rationale: Compare the client’s home medications with the provider’s prescriptions. Verify the client’s name when administering medication, the nurse should call the pharmacy when medications are not available, and a client’s home meds should be secured.

Question 5 of 5

A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse’s priority?

Correct Answer: B

Rationale: Determine the reasons why the client is refusing to use the incentive spirometer.

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