a nurse is preparing to insert an indwelling urinary catheter what is the most important action to prevent infection
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Nursing Elites

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?

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 nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct answer: D

Rationale: The correct answer is D, poor impulse control. Right hemisphere strokes commonly affect judgment and safety awareness, leading to poor impulse control. Choices A, B, and C are incorrect for this scenario. Deficits in the right visual field are associated with left hemisphere strokes, while the inability to discriminate words and letters is typically seen with left hemisphere damage. Motor retardation is more common in strokes affecting the motor areas of the brain, not specifically related to right hemisphere strokes.

3. A nurse is teaching a client about levothyroxine for primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?

Correct answer: D

Rationale: Tremors, nervousness, and insomnia indicate that the dose may be too high, requiring a dose adjustment.

4. A healthcare provider is reviewing the laboratory report of a client who is receiving heparin therapy for a deep vein thrombosis. Which of the following lab values indicates a therapeutic response to the therapy?

Correct answer: B

Rationale: An aPTT of 70 seconds is within the therapeutic range for a client receiving heparin therapy. The activated partial thromboplastin time (aPTT) is the most sensitive test to monitor heparin therapy. A therapeutic aPTT range for a client receiving heparin is usually 1.5 to 2.5 times the control value. Choices A, C, and D are not indicators of a therapeutic response to heparin therapy. PT measures the extrinsic pathway of coagulation and is not specific to monitoring heparin therapy. Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not indicate the therapeutic response to heparin therapy. INR is used to monitor warfarin therapy, not heparin therapy.

5. What are the nursing considerations when caring for a patient with chronic obstructive pulmonary disease (COPD)?

Correct answer: A

Rationale: The correct answer is A. Pursed-lip breathing is a nursing consideration for patients with COPD as it helps improve oxygenation and reduces air trapping. While administering bronchodilators and corticosteroids (choice B) is part of the treatment plan, it is typically done by healthcare providers. Monitoring oxygen saturation and arterial blood gases (ABGs) (choice C) is important but not a direct nursing consideration. Teaching the patient how to use an inhaler (choice D) is relevant but not specific to COPD care.

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