ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. A patient receiving chemotherapy has developed neutropenia. What should be included in the care plan to reduce infection risk?
- A. Monitor temperature daily
- B. Limit visitors
- C. Administer antibiotics prophylactically
- D. Use reverse isolation precautions
Correct answer: D
Rationale: When a patient receiving chemotherapy develops neutropenia, the priority is to reduce the risk of infection. Using reverse isolation precautions is crucial in this situation to protect the patient from exposure to pathogens. Monitoring temperature daily (Choice A) is important but is not as effective as isolating the patient. Limiting visitors (Choice B) can help reduce the risk of exposure, but reverse isolation is a more stringent measure. Administering antibiotics prophylactically (Choice C) is not recommended unless there is a specific indication, as it can contribute to antibiotic resistance.
2. A client has a new prescription for clopidogrel. Which of the following instructions should the nurse include?
- A. Take this medication with food
- B. Take this medication three times daily
- C. You might have to stop taking this medication 5 days before any planned surgeries
- D. Expect to have black-colored stools while taking this medication
Correct answer: C
Rationale: The correct answer is C. When instructing a client who is prescribed clopidogrel, the nurse should include information about stopping the medication 5 days before any planned surgeries to reduce the risk of bleeding. This is crucial to prevent excessive bleeding during surgical procedures. Choices A, B, and D are incorrect because taking the medication with food, the frequency of administration, and the possibility of black-colored stools are not specific instructions related to clopidogrel use.
3. A nurse is caring for a patient who has just returned from surgery. What is the nurse's priority action?
- A. Monitor the patient's pain level.
- B. Assess the patient's vital signs.
- C. Assess the surgical incision site.
- D. Position the patient in a high Fowler's position.
Correct answer: B
Rationale: The correct answer is B: Assess the patient's vital signs. Assessing vital signs is crucial as it helps to detect any early signs of complications such as bleeding, shock, or changes in oxygenation. Monitoring the patient's pain level (Choice A) is important but assessing vital signs takes precedence. While assessing the surgical incision site (Choice C) is essential, ensuring the patient's physiological stability through vital sign assessment is the priority. Positioning the patient in a high Fowler's position (Choice D) may be necessary for comfort but does not address the immediate need to assess the patient's condition post-surgery.
4. When working with a client who does not speak the same language, which of the following actions should the nurse take?
- A. Speak directly to the interpreter
- B. Use family members to translate
- C. Speak directly to the patient
- D. Use medical jargon
Correct answer: C
Rationale: When caring for a client who does not speak the same language, it is essential for the nurse to speak directly to the patient. This approach helps maintain rapport, establishes a trusting relationship, and ensures better communication. Speaking to the interpreter instead of the patient can lead to misunderstandings and hinder the therapeutic relationship. Using family members to translate is not recommended as they may not provide accurate or confidential information. Lastly, using medical jargon can further complicate communication and may not be understood by the patient.
5. Which principle is most important for maintaining medical asepsis in a healthcare setting?
- A. Sterilize instruments only when visibly contaminated.
- B. Use sterile gloves for all patient interactions.
- C. Disinfect patient areas only at the end of the day.
- D. Clean hands thoroughly before and after patient contact.
Correct answer: D
Rationale: The correct answer is D: Clean hands thoroughly before and after patient contact. Hand hygiene is crucial for maintaining medical asepsis in a healthcare setting as it helps prevent the spread of infections between patients and healthcare workers. Choice A is incorrect because instruments should be sterilized regularly, not just when visibly contaminated. Choice B is incorrect as sterile gloves are not required for all patient interactions, only for specific procedures. Choice C is incorrect because patient areas should be disinfected regularly throughout the day, not just at the end of the day.
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