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?
- A. Donning sterile gown and gloves to remove the wound dressing
- B. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
- C. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
- D. Donning clean goggles, gown, and gloves to dress the wound
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. Which question is essential during screening for alcohol use disorder?
- A. What is your current employment status?
- B. Have you experienced any blackouts or loss of consciousness?
- C. Have you been sleeping well over the past month?
- D. Do you have a family history of substance use?
Correct answer: B
Rationale: The essential question during screening for alcohol use disorder is asking about blackouts or loss of consciousness, which can be indicative of excessive drinking and related to alcohol use disorder. Choices A, C, and D are not as directly related to screening for alcohol use disorder. Employment status (Choice A) is not a primary question in alcohol use disorder screening. Sleep quality (Choice C) and family history of substance use (Choice D) may be relevant but are not as crucial as inquiring about blackouts or loss of consciousness.
3. A patient is receiving a blood transfusion and develops chills, a headache, and low back pain. What is the nurse’s priority action?
- A. Administer acetaminophen
- B. Stop the transfusion
- C. Slow the transfusion rate
- D. Administer antihistamines
Correct answer: B
Rationale: The correct answer is to stop the transfusion (Choice B). The symptoms described - chills, headache, and low back pain - are indicative of a transfusion reaction. The priority action is to immediately stop the transfusion to prevent further complications such as more severe reactions like hemolytic reactions or anaphylaxis. Administering acetaminophen (Choice A) may help with symptoms but does not address the underlying cause. Slowing the transfusion rate (Choice C) may not be sufficient if a serious transfusion reaction is occurring. Administering antihistamines (Choice D) is not the priority in this situation; stopping the transfusion takes precedence to ensure patient safety.
4. A client has bilateral eye patches following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
- A. Explain to the client that their tray is here and place their hands on it
- B. Ask the client if they would prefer a liquid diet
- C. Assign an assistive personnel to feed the client
- D. Describe to the client the location of the food on the tray
Correct answer: D
Rationale: Describing the location of food on the tray helps promote independence for the client with bilateral eye patches. By providing clear instructions on where the food is placed, the client can independently locate and consume their meal. Option A is incorrect as physically placing the client's hands on the tray does not encourage independence. Option B is unnecessary unless there are specific dietary restrictions indicated. Option C does not promote the client's independence and should be avoided unless absolutely necessary.
5. A nurse manager is teaching a group of employees about standards for Quality and Safety Education for Nurses (QSEN). Which of the following statements by an employee should the nurse manager identify as an example of the QSEN concept of quality improvement?
- A. We should start tracking how soon clients are discharged after laparoscopic versus open surgery.
- B. We should involve our clients' partners in care planning as much as possible.
- C. We should be sure to log out of the computers immediately following documentation.
- D. We should provide change-of-shift report as a team, including the assistive personnel who assisted with care.
Correct answer: B
Rationale: Involving partners in care planning is a quality improvement strategy that aligns with QSEN principles. This choice reflects patient-centered care and collaboration, which are essential elements of quality improvement. Choices A, C, and D do not directly relate to quality improvement concepts. Tracking discharge times, logging out of computers, and providing change-of-shift reports are important practices but not specifically focused on quality improvement.
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