ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?
- A. Use sterile gloves during the procedure.
- B. Clean the catheter insertion site with alcohol.
- C. Insert the catheter as quickly as possible.
- D. Use a smaller catheter size to minimize trauma.
Correct answer: A
Rationale: Using sterile gloves during catheter insertion is crucial to prevent infection. Sterile gloves help maintain asepsis during the procedure, reducing the risk of introducing microorganisms into the urinary tract. Cleaning the insertion site with alcohol, as mentioned in choice B, is important but not as critical as using sterile gloves. Choice C, inserting the catheter as quickly as possible, is not recommended as it can lead to errors and increase the risk of contamination. Choice D, using a smaller catheter size to minimize trauma, is not directly related to preventing infection but rather focuses on patient comfort and reducing tissue damage.
2. Which finding in a postoperative patient requires immediate intervention by the nurse?
- A. Heart rate of 88 beats per minute.
- B. Blood pressure of 130/80 mmHg.
- C. Crackles heard in the lung bases.
- D. Oxygen saturation of 88% on room air.
Correct answer: D
Rationale: In a postoperative patient, an oxygen saturation level of 88% on room air indicates a significant drop below the normal range, suggesting potential respiratory distress. This finding requires immediate intervention by the nurse to ensure the patient receives adequate oxygenation. A heart rate of 88 beats per minute is within the normal range, making it a less concerning finding. A blood pressure of 130/80 mmHg falls within the normal range for blood pressure and does not require immediate intervention. Crackles heard in the lung bases may indicate fluid accumulation but may not always require immediate intervention unless accompanied by other concerning signs or symptoms.
3. A nurse is caring for a client with pneumonia who has a new prescription for antibiotics. Which of the following actions should the nurse take first?
- A. Administer the antibiotic immediately
- B. Obtain a sputum culture
- C. Notify the provider of the prescription
- D. Check the client's allergy history
Correct answer: B
Rationale: The correct first action for the nurse to take when caring for a client with pneumonia who has a new prescription for antibiotics is to obtain a sputum culture. This is important to identify the specific bacteria causing the pneumonia before administering antibiotics. Administering the antibiotic immediately (Choice A) may not be appropriate without knowing the specific pathogen. Notifying the provider of the prescription (Choice C) is important but not the first action to be taken. Checking the client's allergy history (Choice D) is relevant but not the priority in this situation.
4. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following instructions should the nurse include?
- A. Bend at the waist when picking up objects.
- B. Avoid lying on the operative side.
- C. Avoid lifting more than 10 lb.
- D. Apply ice to the affected eye.
Correct answer: C
Rationale: The correct answer is C: 'Avoid lifting more than 10 lb.' After a cataract extraction, the nurse should instruct the client to avoid lifting heavy objects to prevent increased intraocular pressure, which could lead to complications. Choices A, B, and D are incorrect. A - 'Bend at the waist when picking up objects' can increase intraocular pressure; B - 'Avoid lying on the operative side' is not a specific concern related to cataract extraction; D - 'Apply ice to the affected eye' is not a standard post-cataract extraction instruction.
5. Which of the following is a correct method of safely using a sterile dressing?
- A. Reuse a dressing that appears clean.
- B. Discard a dressing after 24 hours of use.
- C. Change a dressing only if there is visible drainage.
- D. Change a dressing every 4 hours regardless of condition.
Correct answer: B
Rationale: The correct method of safely using a sterile dressing is to discard it after 24 hours of use. This is important to prevent contamination and promote proper wound healing. Choice A is incorrect because reusing a dressing, even if it appears clean, can introduce contaminants. Choice C is incorrect as dressing changes should not be based solely on visible drainage; they should be done within the recommended time frame. Choice D is incorrect because changing a dressing every 4 hours, regardless of its condition, can lead to unnecessary wastage and disturbance to the wound healing process.
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