a nurse is caring for a patient with an infection which laboratory result is most important to monitor
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. A nurse is caring for a patient with an infection. Which laboratory result is most important to monitor?

Correct answer: A

Rationale: The correct answer is A: White blood cell count (WBC). Monitoring the white blood cell count is crucial when caring for a patient with an infection as it helps assess the body's response to the infection. An elevated white blood cell count often indicates an active infection or inflammation, while a decreasing count may signal improvement or potential complications. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) are nonspecific markers of inflammation and not as specific to monitoring infection progression as the white blood cell count. Hemoglobin and hematocrit levels are important for assessing oxygen-carrying capacity and blood volume, but they are not the primary indicators for monitoring infection.

2. When a nurse is assigned to float to another unit and feels unprepared, what is the most appropriate course of action?

Correct answer: B

Rationale: When a nurse is assigned to float to another unit and feels unprepared, the most appropriate course of action is to request help and clarification from the charge nurse. This allows the nurse to address any concerns, seek guidance, and ensure safe patient care. Refusing the assignment (Choice A) is not a constructive approach as it may leave the unit short-staffed and compromise patient safety. Completing the assignment and documenting concerns later (Choice C) is not recommended as it delays addressing the issues at hand. Filing a formal complaint with hospital administration (Choice D) should be considered only after attempting to resolve the issue at the unit level first.

3. A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct answer: D

Rationale: The correct answer is D, poor impulse control. Right hemisphere strokes commonly affect judgment and safety awareness, leading to poor impulse control. Choices A, B, and C are incorrect for this scenario. Deficits in the right visual field are associated with left hemisphere strokes, while the inability to discriminate words and letters is typically seen with left hemisphere damage. Motor retardation is more common in strokes affecting the motor areas of the brain, not specifically related to right hemisphere strokes.

4. What is an expected finding during the assessment of a client transitioning into a new role?

Correct answer: B

Rationale: During a client's transition into a new role, the presence of suicidal or homicidal ideation should be assessed due to the increased risk associated with significant life changes. This finding could indicate a need for immediate intervention. While assessing the client's ability to express feelings of guilt is important, it may not be the most critical aspect during this specific assessment. Changes in coping skills over time are relevant but might not be the primary focus during a role transition assessment. The client's involvement in community activities, although beneficial for social support, is not directly related to the immediate concerns of assessing a client transitioning into a new role.

5. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

Correct answer: A

Rationale: The correct answer is A. Cleansing the bag every 24 hours can lead to contamination, increasing the risk of infection and diarrhea. Using tap water (choice C) is not recommended for cleaning the gastrostomy tube due to the risk of introducing harmful microorganisms. Cleansing the bag every 48 hours (choice B) is not frequent enough and may also contribute to infection. Flushing the tube every 4 hours (choice D) is a standard practice to ensure patency and should not be intervened by the nurse.

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