the nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit which items will the nurse n

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. The nurse has received a report from the emergency department that a patient with tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient?

A. N95 respirator, gown, gloves, eyewear
B. Communication signs for droplet precautions
C. Negative-pressure airflow in room
D. Communication signs for airborne precautions

Correct answer: A

Rationale: The correct answer is A. Caring for a patient with tuberculosis requires the nurse to use an N95 respirator, gown, gloves, and eyewear to protect against airborne transmission of the disease. Choice B and D are incorrect because while communication signs for precautions are important, the essential items needed for caring for a patient with tuberculosis are personal protective equipment to prevent transmission. Choice C is also incorrect as negative-pressure airflow in the room is a facility-related requirement and not an item carried by the nurse.

2. A nurse is teaching a client about signs of infection after surgery. What statement indicates further teaching is required?

A. Redness and swelling are normal after surgery
B. Any drainage from the incision site is not concerning
C. Yellow drainage is normal
D. I should monitor for increased redness or warmth

Correct answer: B

Rationale: The correct answer is B. Any drainage from the incision site should be monitored, and any signs of infection, such as increased redness or warmth, need to be reported to the healthcare provider. Choices A, C, and D provide accurate information about signs of infection after surgery and do not indicate a need for further teaching.

3. A patient is at risk for impaired skin integrity. What is the priority intervention for the nurse?

A. Turn and reposition the patient every 2 hours.
B. Apply a moisture barrier to the patient's skin.
C. Massage the patient's skin to promote circulation.
D. Apply a heating pad to the patient's skin to increase blood flow.

Correct answer: A

Rationale: The correct answer is to turn and reposition the patient every 2 hours. This intervention is crucial in preventing pressure ulcers and maintaining skin integrity by relieving pressure on bony prominences. Applying a moisture barrier (Choice B) is important for moisture-associated skin damage but is not the priority in this case. Massaging the patient's skin (Choice C) can potentially cause friction and shear, increasing the risk of skin breakdown. Applying a heating pad (Choice D) can lead to burns or thermal injuries, exacerbating skin integrity issues.

4. Which action by a nurse demonstrates effective communication with a patient?

A. Providing the patient with written information about their care.
B. Maintaining eye contact and listening actively to the patient.
C. Using medical jargon to explain the patient's condition.
D. Speaking with the patient in a hurried manner to save time.

Correct answer: B

Rationale: Maintaining eye contact and actively listening to the patient is crucial in effective communication as it helps build rapport, shows empathy, and ensures that the patient feels heard and understood. Providing written information can be helpful, but the direct interaction is essential for effective communication. Using medical jargon may confuse the patient instead of clarifying their condition. Speaking hurriedly can make the patient feel rushed and not valued, hindering effective communication.

5. What are the instructions for a behind-the-ear hearing aid?

A. Remove before sleeping
B. Remove before shower
C. Keep on during all activities
D. Replace every week

Correct answer: B

Rationale: The correct answer is to remove a behind-the-ear hearing aid before showering to prevent water damage. Choice A is incorrect because it is safe to wear the hearing aid while sleeping as it does not pose a risk of damage. Choice C is incorrect because it is advisable to remove the hearing aid during certain activities to prevent damage or loss. Choice D is incorrect as hearing aids do not need to be replaced weekly unless there is an issue with the device.