the nurse is caring for a patient with an incision which actions will best indicate an understanding of medical and surgical asepsis for a sterile dre
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?

Correct answer: C

Rationale: Choice C is the correct answer. When performing a sterile dressing change, it is essential to use clean gloves to remove soiled dressings and sterile gloves and supplies for applying the new dressing. This helps maintain aseptic technique and reduce the risk of introducing pathogens to the wound. Choices A, B, and D involve incorrect use of sterile and clean supplies, which can compromise the sterility of the procedure and increase the risk of infection.

2. What intervention should the nurse implement for a patient receiving a blood transfusion?

Correct answer: B

Rationale: The correct intervention for a patient receiving a blood transfusion is to monitor the patient for signs of circulatory overload. This is crucial to prevent fluid overload, which can lead to serious complications. Administering antihistamines is not a routine intervention during blood transfusions unless the patient shows signs of an allergic reaction. Ensuring the completion of the blood transfusion within a specific time frame is not as critical as monitoring for circulatory overload. Checking vital signs every 30 minutes is essential, but the specific focus should be on monitoring for signs of circulatory overload.

3. The emergency department has been notified of a potential bioterrorism attack. Which action by the nurse is priority?

Correct answer: D

Rationale: During a potential bioterrorism attack, the priority for the nurse is to manage all patients using standard precautions. This approach ensures the safety of both patients and healthcare providers by preventing the spread of potential bioterrorism-related illnesses. Option A is incorrect because managing patient care and safety through standard precautions takes precedence. Option B is incorrect as patient transport should also be done while adhering to infection control measures. Option C is incorrect as monitoring for specific symptoms is important but not the priority when all patients need to be managed with standard precautions.

4. What is the most appropriate action for a healthcare provider to take when a patient refuses a prescribed medication?

Correct answer: D

Rationale: The correct answer is to respect the patient's right to refuse the medication. It is crucial to uphold the patient's autonomy and decision-making capacity when it comes to their treatment. Administering the medication later without the patient's consent (Choice B) disregards their autonomy and can lead to ethical issues. Documenting the refusal and notifying the healthcare provider (Choice A) is important for legal and continuity of care purposes but should come after respecting the patient's decision. While explaining the importance of the medication (Choice C) is valuable for promoting understanding and compliance, the immediate concern should be respecting the patient's refusal.

5. Which intervention is most effective in managing a patient with chronic pain?

Correct answer: B

Rationale: The most effective intervention in managing a patient with chronic pain is teaching the patient relaxation techniques. Relaxation techniques can help reduce stress, decrease muscle tension, and improve pain management in patients with chronic pain. Administering opioids as prescribed may have risks of dependence and side effects, making it less favorable as a first-line intervention. Encouraging range of motion exercises can be beneficial, but relaxation techniques directly target stress reduction, a common exacerbating factor in chronic pain. Recommending complete bed rest is generally discouraged in chronic pain management as it can lead to deconditioning and worsen pain over time.

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