Practice Question
When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse?
Answer Choices:
Correct Answer:
The drainage tubing is secured over the siderail.
Rationale:
🔷 Tubing draped over the siderail can cause backflow of urine, increasing the risk of catheter-associated urinary tract infection (CAUTI).
🔷 The drainage bag should be below bladder level and attached to the bed frame, not the siderail.
🔷 An open clamp is correct, as urine must flow freely.
🔷 No dependent loops in tubing is desirable to prevent urinary stasis.
🔷 The most urgent intervention is to reposition the tubing to restore gravity drainage and prevent infection.
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This question is from Hesi Fundamentals pre-assessment 2 which contains 55 questions.
More Questions from This Exam
A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite a clock use of oxycodone and amitriptyline for pain control at home. During the admission assessment, which information is m important for the nurse to obtain?
Answer Choices:
A. Sensory pattern, area, intensity, and nature of the pain.
B. Trigger points identified by palpation and manual pressure of painful areas.
C. Sympathetic responses consistent with onset of acute pain.
D. Schedule and total dosages of drugs currently used for breakthrough pain
The home health nurse visits an older adult client who had a stroke three months ago and is now able to ambulate assistance of a quad cane. Which assessment finding has the greatest implications for this client's care?
Answer Choices:
A. The nurse notes that there are numerous scatter rugs throughout the house.
B. The client reports to the nurse not having much of an appetite today.
C. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.
D. The spouse, who is the caregiver, begins to weep when the nurse asks how the spouse is feeling.
The nurse working in the emergency department is assessing four clients' ability to tolerate pain. Which client is likely to higher level of pain?
Answer Choices:
A. A 70-year-old who has a postoperative infection from a surgery one week ago.
B. A 55-year-old woman who has had moderate low back pain for three months.
C. A 10-year-old who was burned by a camp fire earlier today.
D. A 23-year-old woman who sprained her knee while bicycling.
An older Hispanic client is seen at the community health clinic with a history of protein malnutrition. Which information should nurse obtain first?
Answer Choices:
A. Grains and legume combinations used by the client.
B. Amount of liquid protein supplements consumed daily.
C. Foods and liquids consumed during the past 24 hours.
D. Usual weekly intake of milk products and red meats.
The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for include in this client's plan of care?
Answer Choices:
A. Impaired gas exchange.
B. Risk for aspiration.
C. Ineffective breathing pattern.
D. Ineffective airway clearance.
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI Exam(s)
- Domain: Hesi Fundamentals of Nursing
- Answer Choices: 4
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