ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. Which principle is most important for maintaining medical asepsis in a healthcare setting?
- A. Sterilize instruments only when visibly contaminated.
- B. Use sterile gloves for all patient interactions.
- C. Disinfect patient areas only at the end of the day.
- D. Clean hands thoroughly before and after patient contact.
Correct answer: D
Rationale: The correct answer is D: Clean hands thoroughly before and after patient contact. Hand hygiene is crucial for maintaining medical asepsis in a healthcare setting as it helps prevent the spread of infections between patients and healthcare workers. Choice A is incorrect because instruments should be sterilized regularly, not just when visibly contaminated. Choice B is incorrect as sterile gloves are not required for all patient interactions, only for specific procedures. Choice C is incorrect because patient areas should be disinfected regularly throughout the day, not just at the end of the day.
2. After surgery, a patient is experiencing pain. What is the nurse's priority action?
- A. Administer pain medication as prescribed.
- B. Assess the patient's pain using a pain scale.
- C. Offer the patient non-pharmacological pain relief methods.
- D. Reassess the patient's pain level after 30 minutes.
Correct answer: B
Rationale: The correct answer is to assess the patient's pain using a pain scale. This is the priority action because it allows the nurse to obtain an objective measure of the patient's pain intensity. By accurately assessing the pain level, the nurse can determine the appropriate intervention, which may include administering pain medication as prescribed (choice A) or offering non-pharmacological pain relief methods (choice C). Reassessing the patient's pain level after 30 minutes (choice D) is important but comes after the initial assessment to evaluate the effectiveness of the interventions implemented.
3. The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions?
- A. Teaches the patient about good nutrition.
- B. Disposes of an uncapped needle in the designated container.
- C. Wears eyewear when emptying the urinary drainage bag.
- D. Dons gloves when wearing artificial nails.
Correct answer: C
Rationale: The correct understanding of standard precautions includes wearing appropriate personal protective equipment to prevent exposure to body fluids. Wearing eyewear when emptying the urinary drainage bag is crucial as it protects the nurse's eyes from potential splashes of body fluids. Teaching the patient about good nutrition (Choice A) is important for overall health but is not directly related to standard precautions. Disposing of an uncapped needle correctly (Choice B) is part of safe needle handling but does not specifically relate to standard precautions. Donning gloves when wearing artificial nails (Choice D) is not a correct understanding of standard precautions, as artificial nails can harbor microorganisms and increase the risk of infection transmission.
4. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?
- A. Mild redness at the incision site.
- B. Increased drainage from the surgical site.
- C. Fever of 101°F.
- D. Normal white blood cell count.
Correct answer: C
Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.
5. A healthcare professional is teaching a patient how to prevent falls at home. Which instruction is most appropriate?
- A. Keep your living space well-lit.
- B. Remove loose rugs and install grab bars in the bathroom.
- C. Use furniture to provide support when walking.
- D. Wear socks without shoes to prevent slipping.
Correct answer: B
Rationale: The most appropriate instruction to prevent falls at home is to remove loose rugs and install grab bars in high-risk areas like the bathroom. This helps eliminate tripping hazards and provides stability for the patient. Keeping the living space well-lit (Choice A) is important but may not directly address fall prevention. Using furniture for support (Choice C) can lead to accidents if the furniture is not stable. Wearing socks without shoes (Choice D) increases the risk of slipping rather than preventing falls.
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