Question

ati fundamental test 2024 (nursing process)
24.a nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. the nurse should monitor the client for which of the following expected outcomes after catheter removal?
a. temporary urinary retention
b. urinary frequency for several days
c. blood - tinged urine
d. highly concentrated urine
25.a nurse is evaluating an older adult client who is receiving end - of - life care and has cheyne - stokes respirations. which of the following observations should the nurse identify as confirmation of this respiratory pattern?
a. breathing ranging from very deep to very shallow with periods of apnea
b. shallow breathing alternating with periods of apnea
c. rapid respirations that are unusually deep and regular
d. an inability to breathe without dyspnea unless sitting upright
26.when auscultating a clients lungs, the nurse identifies crackles in the left posterior base. which of the following actions should the nurse take?
a. repeat the auscultation after asking the client to breathe deeply and cough.
b. instruct the client to limit fluid intake to less than 2,000 ml/day.
c. prepare to administer antibiotics.
d. initiate bedrest in semi - fowlers position.
27.a nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. which of the following numbers should the nurse document to indicate the intensity of the clients edema?
a. 4+
b. 3+
c. 2+
d. 1+

Explanation:

• Question 24: After indwelling urinary catheter removal, especially in older adults, temporary urinary retention can occur as the bladder muscle may need time to regain normal function. Urinary frequency for several days is not an expected outcome. Blood - tinged urine may indicate trauma (not expected here). Highly concentrated urine is more related to fluid intake than catheter removal.
• Question 25: Cheyne - Stokes respirations are characterized by breathing ranging from very deep to very shallow with periods of apnea. Shallow breathing alternating with apnea is not the classic Cheyne - Stokes. Rapid, unusually deep and regular respirations are more like Kussmaul's. Inability to breathe without dyspnea unless sitting upright is orthopnea.
• Question 26: Crackles can sometimes be due to atelectasis (collapsed alveoli). Asking the client to breathe deeply and cough can help re - expand alveoli. Limiting fluid intake is not the first action for crackles. Preparing to administer antibiotics is premature without a diagnosis of infection. Initiating bedrest in semi - Fowler's is not the first step.
• Question 27: For pitting edema, an indentation of 6mm (0.25 in) corresponds to a 3+ rating. A 4+ is a deeper indentation (8mm or more), 2+ is around 4mm, and 1+ is 2mm.

Answer:

1. A. Temporary urinary retention
2. A. Breathing ranging from very deep to very shallow with periods of apnea
3. A. Repeat the auscultation after asking the client to breathe deeply and cough
4. B. 3+