ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN
1. Which of the following is the correct method to reduce the risk of infection when handling a urinary catheter?
- A. Clean the catheter tubing with soap and water.
- B. Maintain sterile technique when inserting the catheter.
- C. Insert the catheter using clean gloves and a clean technique.
- D. Flush the catheter tubing regularly with sterile water.
Correct answer: B
Rationale: The correct method to reduce the risk of infection when handling a urinary catheter is to maintain sterile technique when inserting the catheter. Sterile technique helps prevent introducing pathogens into the urinary system, reducing the risk of infection. Choice A is incorrect because cleaning the catheter tubing with soap and water is not sufficient for preventing infection. Choice C is incorrect as clean gloves and technique are not enough; sterile technique is necessary. Choice D is incorrect as flushing the catheter tubing with sterile water, though important for maintaining catheter patency, does not address the need for sterile technique during insertion to prevent infection.
2. A nurse is caring for a client and realizes they have administered the wrong medication. Which of the following actions should the nurse take first?
- A. Notify the provider
- B. Check the condition of the client
- C. Document the occurrence in the electronic medical record
- D. Complete an incident report
Correct answer: B
Rationale: The correct answer is to 'Check the condition of the client' first. When a medication error occurs, the nurse's initial priority should be to assess the client's condition to address any immediate harm or side effects. Notifying the provider can come after ensuring the client's safety. Documenting the occurrence in the electronic medical record and completing an incident report are important steps but should follow the assessment of the client's condition to prioritize patient safety.
3. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?
- A. Closes the door to the client's room
- B. Flushes the client's toilet after emptying the urinary catheter's drainage bag
- C. Measures the client's vital signs routinely
- D. Asks a group of personnel in the hall to speak quietly
Correct answer: B
Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.
4. A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?
- A. Wipe the area around the needleless port with sterile water
- B. Insert the syringe into the needleless port at a 60-degree angle
- C. Withdraw 3 to 5 ml of urine from the port
- D. Don sterile gloves
Correct answer: C
Rationale: The correct action for the nurse to take is to withdraw 3 to 5 ml of urine from the port for an accurate culture and sensitivity test. Wiping the area around the needleless port with sterile water (Choice A) is not necessary when obtaining a urine specimen. Inserting the syringe into the needleless port at a 60-degree angle (Choice B) is incorrect as it does not align with the correct procedure for obtaining a urine specimen. Donning sterile gloves (Choice D) is a good practice but not the immediate action required for obtaining a urine specimen.
5. The client has a do-not-resuscitate (DNR) order. The family asks the nurse to ignore the DNR if the client codes. What is the nurse's responsibility?
- A. Follow the family's wishes
- B. Explain that the DNR must be honored
- C. Ignore the DNR and proceed with CPR
- D. Perform CPR if the client codes
Correct answer: B
Rationale: The correct answer is B: 'Explain that the DNR must be honored.' The nurse's responsibility is to follow the DNR order, as it is a legal and ethical obligation. Choice A is incorrect because following the family's wishes would go against the established DNR order. Choice C is incorrect as ignoring the DNR order is not appropriate. Choice D is also incorrect as performing CPR would be contrary to the client's expressed wishes in the DNR order.
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