a nurse is assessing a patient with pneumonia which finding is most concerning
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. A healthcare professional is assessing a patient with pneumonia. Which finding is most concerning?

Correct answer: D

Rationale: Crackles heard in the lung bases are most concerning in a patient with pneumonia as they suggest fluid accumulation in the lungs, indicating possible severe infection or respiratory distress. Prompt intervention is required to prevent further complications.\n\nChoice A, fever of 101°F, is common in infections like pneumonia but may not be as immediately concerning as crackles indicating fluid in the lungs.\n\nChoice B, a blood pressure of 140/90 mmHg, is within normal limits and not directly indicative of pneumonia severity.\n\nChoice C, a heart rate of 95 beats per minute, is slightly elevated but not as critical as crackles suggesting fluid in the lungs.

2. The nurse is caring for a patient on contact precautions. Which action will be most appropriate to prevent the spread of disease?

Correct answer: D

Rationale: The correct answer is to use a dedicated blood pressure cuff that stays in the room and is used for that patient only. Patients on contact precautions require dedicated equipment to prevent the spread of disease. Using one blood pressure cuff exclusively for the patient on contact precautions helps minimize the risk of transmitting infections to other patients. Choices A, B, and C are incorrect because while wearing protective gear and isolating the patient in a room with negative airflow are important infection control measures, using dedicated equipment for the patient on contact precautions is specifically recommended to prevent the spread of disease in this scenario.

3. A nurse is providing teaching to the parent of a child who is receiving oral nystatin for oral candidiasis. Which of the following statements by the parent indicates an understanding of the teaching?

Correct answer: D

Rationale: The correct answer is D because swabbing the inside of the child's mouth with the nystatin solution is the correct administration method for treating oral candidiasis. Mixing the medication with applesauce or providing a snack with it is not the recommended method of administration. Storing the medication in the refrigerator is also unnecessary and not part of the proper administration instructions.

4. A client scheduled for a CT scan of the head with contrast is being taught by a nurse. Which of the following statements by the client indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D because metformin should be held before a contrast CT scan to prevent the risk of kidney damage. Choices A, B, and C are all correct statements regarding the preparation and experience of a CT scan with contrast. It is important to fast before the procedure, keep the head still during the scan, and expect a warm sensation when the dye is injected.

5. A nurse notices another nurse skipping hand hygiene. What is the appropriate course of action?

Correct answer: B

Rationale: Correct hand hygiene is crucial for preventing the spread of infections and ensuring patient safety. When a nurse observes another healthcare worker skipping hand hygiene practices, it is essential to report this behavior to the supervisor. Reporting ensures that appropriate action is taken to address the issue and maintain a safe environment for patients. Ignoring the situation (Choice A) may compromise patient safety. Discussing the issue directly with the nurse (Choice C) may not always be effective in ensuring compliance. Doing nothing and continuing with patient care (Choice D) disregards the importance of infection control protocols.

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