what is the most important nursing action when caring for a patient with a central venous catheter cvc
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?

Correct answer: B

Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.

2. During a home visit with an older adult client, a nurse should address which of the following observations to promote a safe environment?

Correct answer: C

Rationale: The correct answer is C: Low chairs without armrests. This observation should be addressed by the nurse to promote a safe environment for the older adult client. Low chairs without armrests increase the risk of falls as they can be challenging for older adults to sit down on or get up from. Addressing this issue can help prevent falls and promote safety. Choices A, B, and D are not as crucial for promoting a safe environment compared to the risk posed by low chairs without armrests.

3. A nurse is preparing to administer ampicillin 500 mg IV bolus every 6 hours. Available is ampicillin 500 mg in 50 mL dextrose 5% in water (D5W) to infuse over 20 minutes. The nurse should set the IV pump to deliver how many mL/hr?

Correct answer: B

Rationale: To infuse 50 mL over 20 minutes, the pump should be set to 150 mL/hr. This calculation ensures the correct rate for the infusion of the medication. Choices A, C, and D are incorrect as they do not align with the correct calculation based on the given information.

4. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient?

Correct answer: A

Rationale: The correct answer is A. Caring for a patient with tuberculosis requires the nurse to use an N95 respirator, gown, gloves, and eyewear to protect against airborne transmission of the disease. Choice B and D are incorrect because while communication signs for precautions are important, the essential items needed for caring for a patient with tuberculosis are personal protective equipment to prevent transmission. Choice C is also incorrect as negative-pressure airflow in the room is a facility-related requirement and not an item carried by the nurse.

5. Which of the following actions is a means of maintaining medical asepsis to reduce and prevent the spread of microorganisms?

Correct answer: A

Rationale: The correct answer is A: Sterilizing contaminated items. Maintaining medical asepsis involves ensuring that items are free of microorganisms to prevent infections. Sterilizing contaminated items is a crucial step in this process as it eliminates all microorganisms, including spores. Choices B, C, and D do not directly address the process of reducing and preventing the spread of microorganisms. While routinely cleaning the hospital environment is important for cleanliness, it does not guarantee the elimination of all microorganisms. Reapplying a sterile dressing and applying a sterile gown and gloves are specific actions related to personal protective equipment and wound care, not the general maintenance of medical asepsis.

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