ATI RN
ATI Capstone Comprehensive Assessment B
1. A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?
- A. The nursing student wears gloves when changing bed linens.
- B. The nursing student wears gloves to remove a wound dressing.
- C. The nursing student washes hands after removing gloves.
- D. The nursing student touches the patient's skin with sterile gloves.
Correct answer: D
Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.
2. What is the priority action for a patient with a fever?
- A. Administer an antipyretic medication as prescribed.
- B. Assess the patient's temperature regularly.
- C. Provide cooling measures such as a cool compress.
- D. Provide the patient with blankets for comfort.
Correct answer: B
Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.
3. A nurse is preparing an in-service about family violence for a group of newly licensed nurses. Which of the following statements should the nurse include in the teaching?
- A. Perpetrators of family-directed violence do not recognize their behavior as abnormal.
- B. Female clients who experience partner violence are at greater risk for chronic diseases.
- C. The victim's risk for homicide is greatest when they decide to leave the relationship.
- D. The level of violence increases over time in abusive relationships.
Correct answer: C
Rationale: The correct answer is C because the risk of homicide increases significantly when a victim decides to leave an abusive relationship. This is a crucial point to emphasize in educating healthcare professionals about family violence. Choice A is incorrect because perpetrators often do not acknowledge their behavior as abnormal. Choice B is incorrect as victims of partner violence are at greater risk for chronic, not acute, diseases. Choice D is incorrect as the level of violence tends to escalate rather than decrease over time in abusive relationships.
4. A client asks about becoming an organ donor. What information should the nurse provide?
- A. The process should be discussed with family first.
- B. The organ donation process should begin immediately.
- C. Organ donation can proceed even if the family disagrees.
- D. Donor cards must be signed in the presence of a witness.
Correct answer: D
Rationale: The correct answer is D. For organ donation to be legally valid, the donor must sign consent documents in the presence of a witness. Choice A is incorrect because while discussing with family is important, it is not a legal requirement for organ donation. Choice B is incorrect as the organ donation process involves various steps and procedures that cannot begin immediately. Choice C is incorrect because organ donation typically requires consent and cooperation from the family if the donor is unable to provide consent.
5. A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?
- A. Use sterile gloves during the procedure.
- B. Clean the catheter insertion site with alcohol.
- C. Insert the catheter as quickly as possible.
- D. Use a smaller catheter size to minimize trauma.
Correct answer: A
Rationale: Using sterile gloves during catheter insertion is crucial to prevent infection. Sterile gloves help maintain asepsis during the procedure, reducing the risk of introducing microorganisms into the urinary tract. Cleaning the insertion site with alcohol, as mentioned in choice B, is important but not as critical as using sterile gloves. Choice C, inserting the catheter as quickly as possible, is not recommended as it can lead to errors and increase the risk of contamination. Choice D, using a smaller catheter size to minimize trauma, is not directly related to preventing infection but rather focuses on patient comfort and reducing tissue damage.
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