a nurse is preparing to insert an indwelling urinary catheter what is the most important action to prevent infection
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. A healthcare professional is preparing to insert an indwelling urinary catheter. What is the most important action to prevent infection?

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.

2. After placing the patient back in bed, what should the nurse do next?

Correct answer: C

Rationale: After placing the patient back in bed, the nurse should notify the health care provider. This is important because the health care provider needs to be informed of the incident and assess the patient further to ensure no underlying injuries or issues exist. Re-assessing the patient is crucial but notifying the health care provider takes precedence in this situation. Completing an incident report is important for documentation purposes but not the immediate next step. Doing nothing is incorrect as there was an incident involving a fall that needs further evaluation.

3. A client with renal calculi is admitted. What is the priority nursing intervention?

Correct answer: C

Rationale: The correct answer is to strain all urine for stones. This is the priority nursing intervention for a client with renal calculi as it helps in identifying and preventing stones from passing unnoticed. Monitoring urinary output, administering pain medication, and increasing fluid intake are important aspects of care for this client, but the priority is to ensure that any passed stones are collected and analyzed to guide further treatment.

4. Which personality disorder is characterized by disregard for others and manipulative behaviors?

Correct answer: B

Rationale: Antisocial Personality Disorder is the correct answer. This disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others. Individuals with this disorder often display behaviors such as manipulation, exploitation, and a lack of empathy. Choice A, Borderline Personality Disorder, is characterized by unstable moods, behavior, and relationships. Choice C, Histrionic Personality Disorder, is characterized by attention-seeking behavior and excessive emotions. Choice D, Narcissistic Personality Disorder, is characterized by a grandiose sense of self-importance, a need for admiration, and a lack of empathy for others.

5. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Correct answer: D

Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.

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