which of the following actions are means of maintaining medical asepsis to reduce and prevent the spread of microorganisms
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Nursing Elites

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RN ATI Capstone Proctored Comprehensive Assessment A

1. 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.

2. The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, 'I always get a rash when I eat shellfish.' Which of the following is the priority nursing action?

Correct answer: D

Rationale: Notifying the provider of the client's shellfish allergy is crucial to prevent a potential reaction from the contrast dye. While attaching a wristband indicating the allergy may be necessary, the priority is to inform the provider. Asking the client about other foods causing a similar reaction or notifying the dietary department, although important, are not the priority in this situation.

3. A client has urinary incontinence, and the nurse is caring for them. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct answer: C

Rationale: The correct action to prevent skin breakdown in a client with urinary incontinence is to apply a moisture barrier ointment to the skin. This ointment helps protect the skin from the harmful effects of moisture exposure, reducing the risk of breakdown. Requesting an indwelling urinary catheter (Choice A) should not be the first-line intervention for skin breakdown prevention. Checking the client's skin for signs of breakdown (Choice B) is important but not as effective as applying a moisture barrier. Cleaning the skin with hot water (Choice D) can actually be detrimental as hot water can strip the skin of its natural oils and worsen skin integrity.

4. Which goal is most appropriate for a patient who has had a total hip replacement?

Correct answer: B

Rationale: Choice B is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, and achievable. Walking 100 feet using a walker is a realistic and individualized target for a patient in the recovery phase following hip surgery. Choices A, C, and D are not as suitable: Choice A does not specify a measurable distance or objective, Choice C sets a potentially unrealistic expectation for brisk ambulation on a treadmill, and Choice D lacks the specificity of the distance to be walked.

5. A patient is receiving a blood transfusion and develops chills, a headache, and low back pain. What is the nurse’s priority action?

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.

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