how should a nurse care for a patient with a central line to prevent infection
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. How should a healthcare professional care for a patient with a central line to prevent infection?

Correct answer: A

Rationale: Corrected Rationale: Changing the central line dressing daily is crucial in preventing infection at the insertion site. This practice helps maintain a clean and sterile environment around the central line, reducing the risk of pathogens entering the bloodstream. Monitoring for redness (choice B) is important but may not directly prevent infection. Checking the central line site every shift (choice C) is essential for early detection of any issues but does not solely prevent infection. Flushing the line with saline (choice D) is a necessary procedure for maintaining central line patency but does not primarily prevent infection.

2. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client's family wants the client to have life-sustaining measures. Which of the following actions should the nurse take?

Correct answer: A

Rationale: In this scenario, the nurse should arrange for an ethics committee meeting to address the family's concerns while ensuring the client's wishes are respected. Choosing option A allows for a formal discussion involving healthcare professionals, family members, and possibly a legal expert to navigate the situation ethically and legally. Supporting the family's decision to initiate life-sustaining measures (option B) would disregard the client's advance directives and autonomy. Completing an incident report (option C) is not appropriate in this situation as it does not address the conflict of interest between the family's desires and the client's wishes. Encouraging the family to contact an attorney (option D) may escalate the situation unnecessarily before exploring more ethical and collaborative approaches.

3. A client who has a new prescription for alendronate is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: C

Rationale: The correct answer is C: "I should remain upright for at least 30 minutes after taking this medication." This statement indicates understanding because clients taking alendronate should remain upright for at least 30 minutes after taking the medication to prevent esophageal irritation. Choice A is incorrect because alendronate should be taken with a full glass of water after waking up, not before breakfast. Choice B is incorrect because alendronate should be taken on an empty stomach, not with food. Choice D is incorrect because alendronate should be taken separately from antacids.

4. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction for a client prescribed nitroglycerin sublingual tablets is to lie down before taking the medication. Nitroglycerin can cause a sudden drop in blood pressure leading to dizziness or fainting, so taking the medication while lying down helps prevent falls. Choice B is incorrect because nitroglycerin is usually taken on an empty stomach to enhance its absorption. Choice C is incorrect as taking a double dose of nitroglycerin can lead to low blood pressure and other adverse effects. Choice D is incorrect as nitroglycerin sublingual tablets should be stored in their original container at room temperature away from light and moisture, not in the refrigerator.

5. A nurse is caring for a client who has undergone a bronchoscopy. Which assessment finding requires immediate intervention?

Correct answer: D

Rationale: An absent gag reflex is a critical finding that requires immediate intervention to prevent aspiration. This can lead to the aspiration of oral or gastric contents into the lungs, potentially causing serious respiratory complications. Oxygen saturation of 95% is within the normal range, a blood pressure of 130/85 mm Hg is also within normal limits, and coughing up small amounts of sputum is an expected finding after a bronchoscopy procedure.

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