a nurse manager assigns a task outside the scope of a nursing assistant how should the assistant respond
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. A nurse manager assigns a task outside the scope of a nursing assistant. How should the assistant respond?

Correct answer: A

Rationale: When a task is assigned that is outside the scope of a nursing assistant, it is essential for the assistant to refuse the task and report it to the charge nurse. This ensures that tasks are appropriately delegated, maintaining patient safety and adherence to professional standards. Performing the task without reporting can lead to potential risks for the patient and legal implications. Asking another nurse to perform the task may not address the issue of improper delegation. Accepting the task but documenting it later does not resolve the immediate concern of working within the assistant's scope of practice and seeking appropriate delegation.

2. What is the priority nursing intervention for a patient with a new tracheostomy?

Correct answer: A

Rationale: The correct answer is to suction the tracheostomy as needed to maintain a patent airway. After a tracheostomy procedure, the immediate concern is airway patency to prevent respiratory compromise. Suctioning helps clear secretions and maintains a clear airway, reducing the risk of respiratory distress. Monitoring the patient's oxygen saturation (choice B) is important but not the priority compared to ensuring a clear airway. Providing humidified air (choice C) and administering pain medication (choice D) are also essential aspects of care for a patient with a tracheostomy, but they are not the priority when immediate airway management is required.

3. A forensic nurse is using the epidemiological triangle to explain factors that contribute to violent behavior. Which of the following factors should the nurse identify as an environmental factor in the epidemiological triangle?

Correct answer: A

Rationale: Crowded living conditions are considered an environmental factor in the epidemiological triangle as they can contribute to the spread of violence. In this context, environmental factors refer to external influences such as social and physical environments. Traumatic brain injury, Alzheimer's disease, and impaired coping abilities are not typically classified as environmental factors in the epidemiological triangle. Traumatic brain injury and Alzheimer's disease are more related to individual health conditions, while impaired coping abilities are more focused on individual psychological factors rather than external environmental influences.

4. Which therapeutic technique is recommended for clients with somatic symptom disorder?

Correct answer: B

Rationale: The correct therapeutic technique recommended for clients with somatic symptom disorder is to limit the amount of time the client spends discussing symptoms. By doing so, the focus can be shifted away from the illness, helping the client to manage their condition better. Encouraging complete bed rest (Choice A) is not typically recommended as it may reinforce illness behaviors. Monitoring the client's food intake (Choice C) may not directly address the psychological aspects of somatic symptom disorder. Educating the client on lifestyle changes (Choice D) is important but may not be as effective initially as limiting symptom-focused discussions.

5. What are the key nursing interventions for a patient experiencing acute respiratory distress syndrome (ARDS)?

Correct answer: A

Rationale: The correct answer is A: Positioning the patient in a prone position. Prone positioning is a key nursing intervention for patients with acute respiratory distress syndrome (ARDS) as it helps improve oxygenation by allowing better lung ventilation. Choice B, monitoring vital signs and lung sounds, is important but not a key intervention specific to ARDS. Choice C, preparing for mechanical ventilation, may be necessary in severe cases of ARDS but is not a primary nursing intervention. Choice D, administering supplemental oxygen, is a common supportive measure but is not specific to ARDS interventions.

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