the nurse is caring for a patient who is at risk for infection which action by the nurse indicates correct understanding about standard precautions
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions?

Correct answer: C

Rationale: The correct understanding of standard precautions includes wearing appropriate personal protective equipment to prevent exposure to body fluids. Wearing eyewear when emptying the urinary drainage bag is crucial as it protects the nurse's eyes from potential splashes of body fluids. Teaching the patient about good nutrition (Choice A) is important for overall health but is not directly related to standard precautions. Disposing of an uncapped needle correctly (Choice B) is part of safe needle handling but does not specifically relate to standard precautions. Donning gloves when wearing artificial nails (Choice D) is not a correct understanding of standard precautions, as artificial nails can harbor microorganisms and increase the risk of infection transmission.

2. What is the most important nursing intervention when caring for a patient with a wound?

Correct answer: B

Rationale: The most important nursing intervention when caring for a patient with a wound is to clean the wound with normal saline. This is crucial for preventing infection and promoting healing. Applying an occlusive dressing (Choice A) can be important but should come after cleaning the wound. Administering antibiotics (Choice C) is not the first-line intervention for all wounds and should be based on the healthcare provider's prescription. Reassessing the wound (Choice D) is essential but not the most important initial intervention.

3. A healthcare provider is providing a report to a colleague about a client who weighs 210 lb and has a prescription for one-third weight bearing on the right leg. How many kg of weight should the client bear on the right leg?

Correct answer: A

Rationale: To calculate the weight-bearing limit, we first need to convert 210 lbs to kg. To do this, we use the conversion factor 1 lb = 0.453592 kg. So, 210 lbs is equal to 210 * 0.453592 = 95.254 kg. One-third of 95.254 kg is 31.7513 kg, which can be rounded to 32 kg. Therefore, the client should bear 32 kg of weight on the right leg. Choice A is the correct answer. Choices B, C, and D are incorrect as they do not reflect the accurate calculation based on the client's weight and the prescribed weight-bearing limit.

4. A client is administering insulin. Which statement by the client shows proper understanding of insulin administration?

Correct answer: D

Rationale: The correct answer is D because rotating injection sites prevents tissue damage and ensures better absorption of insulin. Option A is incorrect as injecting insulin into the thigh before exercise can lead to hypoglycemia. Option B is incorrect as skipping meals can cause blood sugar levels to drop dangerously low. Option C is incorrect as insulin should not be stored in the freezer as it can alter its effectiveness.

5. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.

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