ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. Which of the following statements reflects the principles of sterile technique?
- A. Sterile objects that come in contact with unsterile objects are to be considered contaminated.
- B. Items in a sterile package must be used immediately once the package has been opened; otherwise, they are considered contaminated.
- C. Any part of a sterile field that hangs below the top of the table is sterile as long as it is not touched.
- D. The edge of a sterile field and a border 1 inch (2.5 cm) inward is unsterile.
Correct answer: A
Rationale: The correct statement reflecting the principles of sterile technique is that sterile objects that come in contact with unsterile objects are considered contaminated. This principle is crucial in maintaining asepsis during medical procedures. Choice B is incorrect because items in a sterile package should only be used if they remain sterile; opening the package does not automatically contaminate the items. Choice C is incorrect as any part of a sterile field that hangs below the top of the table is considered unsterile. Choice D is incorrect as the edge of a sterile field and a border inward are typically considered unsterile to maintain the integrity of the sterile area.
2. A nurse manager assigns a nursing assistant a task outside of their role. What should the nursing assistant do?
- A. Follow the manager's directive
- B. Report the task to the charge nurse
- C. Refuse to perform the task
- D. Perform the task and document later
Correct answer: B
Rationale: If a nurse manager assigns a nursing assistant a task that is outside of their role, the nursing assistant should report the task to the charge nurse. This is important because the charge nurse can provide guidance on whether the task is appropriate for the nursing assistant to perform. Choice A is incorrect because blindly following a directive that is outside of the nursing assistant's scope could lead to negative consequences. Choice C might not be the best course of action initially, as it's important to seek clarification first. Choice D is also not the best option because performing a task outside of one's role without proper authorization can pose risks to both the patient and the nursing assistant.
3. A nurse is caring for a client with a new colostomy. What is the nurse's responsibility regarding stoma care?
- A. Educate the client on how to care for the stoma independently.
- B. Contact the stoma nurse to assist the client with care.
- C. Delegate the care of the stoma to a nursing assistant.
- D. Wait until the next shift to address the stoma care.
Correct answer: B
Rationale: The correct answer is to contact the stoma nurse to assist the client with care. Stoma nurses are specially trained to provide guidance on stoma care, especially for clients with new ostomies. Instructing the client to care for the stoma independently (Choice A) may not be appropriate initially as they may need professional guidance. Delegating the care of the stoma to a nursing assistant (Choice C) is not recommended as specialized care is required. Waiting until the next shift (Choice D) is not ideal as stoma care should not be delayed.
4. What is the most appropriate method for assessing a patient's pain level?
- A. Observe the patient's facial expressions.
- B. Use a standardized pain scale, such as 0-10.
- C. Ask the patient to rate their pain based on their mood.
- D. Ask the patient's family members to assess the pain.
Correct answer: B
Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.
5. Which of the following is the correct method to reduce the risk of infection when handling a urinary catheter?
- A. Clean the catheter tubing with soap and water.
- B. Maintain sterile technique when inserting the catheter.
- C. Insert the catheter using clean gloves and a clean technique.
- D. Flush the catheter tubing regularly with sterile water.
Correct answer: B
Rationale: The correct method to reduce the risk of infection when handling a urinary catheter is to maintain sterile technique when inserting the catheter. Sterile technique helps prevent introducing pathogens into the urinary system, reducing the risk of infection. Choice A is incorrect because cleaning the catheter tubing with soap and water is not sufficient for preventing infection. Choice C is incorrect as clean gloves and technique are not enough; sterile technique is necessary. Choice D is incorrect as flushing the catheter tubing with sterile water, though important for maintaining catheter patency, does not address the need for sterile technique during insertion to prevent infection.
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