ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. The family member is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings?
- A. The family member saves part of the dressing because it is clean.
- B. The family member places the used dressings in a plastic bag.
- C. The family member removes gloves and gathers items for disposal.
- D. The family member wraps the used dressing in toilet tissue before placing it in the trash.
Correct answer: B
Rationale: The correct way to manage contaminated dressings is to place them in plastic bags for proper disposal. This helps prevent the spread of infection. Choice A is incorrect because saving part of the dressing is not a recommended practice. Choice C is not directly related to managing contaminated dressings. Choice D is incorrect as wrapping the used dressing in toilet tissue is not the appropriate way to dispose of contaminated dressings.
2. A client undergoing chemotherapy expresses concern about hair loss. What should the nurse suggest?
- A. Encourage the client to cut their hair short before chemotherapy.
- B. Provide resources for wigs or hairpieces.
- C. Assure the client that hair loss will be minimal.
- D. Offer the client medication to reduce the chances of hair loss.
Correct answer: B
Rationale: The correct answer is B: Providing wigs and other coping resources helps clients manage the emotional effects of chemotherapy-related hair loss. Encouraging the client to cut their hair short before chemotherapy (Choice A) is not necessary as hair loss may still occur. Assuring the client that hair loss will be minimal (Choice C) may provide false hope as hair loss is a common side effect of chemotherapy. Offering medication to reduce hair loss (Choice D) is not a typical approach as chemotherapy-related hair loss is often an expected side effect that cannot be entirely prevented with medication.
3. What are the nursing interventions for a patient with pneumonia?
- A. Providing fluids and rest
- B. Monitoring lung sounds and respiratory rate
- C. Encouraging coughing and deep breathing exercises
- D. Administering antibiotics and providing oxygen therapy
Correct answer: B
Rationale: The correct nursing interventions for a patient with pneumonia include monitoring lung sounds and respiratory rate to assess the effectiveness of treatment and the patient's respiratory status. Providing fluids and rest (Choice A) can be supportive measures but are not specific nursing interventions for pneumonia. Encouraging coughing and deep breathing exercises (Choice C) can be helpful for airway clearance but may not be appropriate for all patients with pneumonia. Administering antibiotics and providing oxygen therapy (Choice D) are medical interventions rather than nursing interventions.
4. A client has a new prescription for clopidogrel. Which of the following instructions should the nurse include?
- A. Take this medication with food
- B. Take this medication three times daily
- C. You might have to stop taking this medication 5 days before any planned surgeries
- D. Expect to have black-colored stools while taking this medication
Correct answer: C
Rationale: The correct answer is C. When instructing a client who is prescribed clopidogrel, the nurse should include information about stopping the medication 5 days before any planned surgeries to reduce the risk of bleeding. This is crucial to prevent excessive bleeding during surgical procedures. Choices A, B, and D are incorrect because taking the medication with food, the frequency of administration, and the possibility of black-colored stools are not specific instructions related to clopidogrel use.
5. Which nursing action will most likely increase a patient's risk for developing a health care-associated infection?
- A. Uses a sterile bottled solution more than once within a 24-hour period.
- B. Uses surgical aseptic technique to suction an airway.
- C. Uses a clean technique for inserting a urinary catheter.
- D. Uses a cleaning stroke from the urinary meatus toward the rectum.
Correct answer: C
Rationale: The correct answer is C. Using a clean technique for inserting a urinary catheter increases the risk for healthcare-associated infections. Invasive procedures like catheter insertion require a sterile technique to prevent introducing pathogens into the urinary tract. Choices A and B demonstrate appropriate infection control measures by emphasizing the use of sterile or aseptic techniques. Choice D represents an incorrect technique that can lead to the introduction of bacteria from the rectum into the urinary tract, potentially causing infections.
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