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. A patient has just undergone a tracheostomy. What is the nurse's priority intervention?
- A. Suction the tracheostomy to maintain a patent airway.
- B. Administer pain medication as prescribed.
- C. Change the tracheostomy dressing every 4 hours.
- D. Monitor the patient's oxygen saturation closely.
Correct answer: A
Rationale: The correct answer is to suction the tracheostomy to maintain a patent airway. After a tracheostomy, the priority intervention is to ensure a clear airway to prevent respiratory distress. Administering pain medication, changing the tracheostomy dressing, and monitoring oxygen saturation are important but are secondary to maintaining a patent airway in a patient who has just undergone a tracheostomy.
3. What are the signs of infection that should be monitored in a postoperative patient?
- A. Fever and chills
- B. All of the above
- C. Increased pain or tenderness
- D. Redness, swelling, and warmth at the surgical site
Correct answer: D
Rationale: The correct answer is D: 'Redness, swelling, and warmth at the surgical site.' These are specific signs of infection at the surgical site that a nurse should monitor for in a postoperative patient. While fever, chills, and increased pain can also indicate infection, the most direct signs are redness, swelling, and warmth at the surgical site. Therefore, 'D' is the best choice as it directly relates to the site of the surgery and is crucial to monitor for potential postoperative infections.
4. Which personality disorder is characterized by disregard for others and manipulative behaviors?
- A. Borderline Personality Disorder
- B. Antisocial Personality Disorder
- C. Histrionic Personality Disorder
- D. Narcissistic Personality Disorder
Correct answer: B
Rationale: Antisocial Personality Disorder is the correct answer. This disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others. Individuals with this disorder often display behaviors such as manipulation, exploitation, and a lack of empathy. Choice A, Borderline Personality Disorder, is characterized by unstable moods, behavior, and relationships. Choice C, Histrionic Personality Disorder, is characterized by attention-seeking behavior and excessive emotions. Choice D, Narcissistic Personality Disorder, is characterized by a grandiose sense of self-importance, a need for admiration, and a lack of empathy for others.
5. 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.
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