the nurse is caring for a patient who is at risk for infection which action by the nurse indicates correct understanding about standard precautions
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. The nurse is caring for a patient who is at risk for infection. Which action by the nurse indicates correct understanding about standard precautions?

Correct answer: C

Rationale: The correct understanding of standard precautions includes wearing appropriate personal protective equipment to prevent exposure to body fluids. Wearing eyewear when emptying the urinary drainage bag is crucial as it protects the nurse's eyes from potential splashes of body fluids. Teaching the patient about good nutrition (Choice A) is important for overall health but is not directly related to standard precautions. Disposing of an uncapped needle correctly (Choice B) is part of safe needle handling but does not specifically relate to standard precautions. Donning gloves when wearing artificial nails (Choice D) is not a correct understanding of standard precautions, as artificial nails can harbor microorganisms and increase the risk of infection transmission.

2. A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client. What is the nurse's responsibility?

Correct answer: B

Rationale: The correct answer is B: 'Educate the client on stoma care.' The nurse's primary responsibility in this scenario is to provide education to the client on stoma care. This empowers the client to take care of their colostomy effectively. While it is important to involve the stoma nurse for specialized care, the immediate action required from the nurse is client education. Choice A is incorrect as the immediate action is not to contact the stoma nurse but to educate the client first. Choice C is not the nurse's initial responsibility unless there are obvious complications. Choice D is premature as arranging follow-up visits should come after the client has been educated and initial care has been provided.

3. A client with a new diagnosis of type 1 diabetes mellitus is being taught about self-administration of insulin by a nurse. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is to store the current bottle of insulin at room temperature. Insulin should be stored this way to maintain its potency and effectiveness. Choice B is incorrect because massaging the injection site after removing the needle is not recommended practice and can cause bruising. Choice C is incorrect as pulling back on the plunger after injecting insulin can lead to injecting air bubbles into the tissue. Choice D is incorrect as syringes should not be reused multiple times due to the risk of contamination and inaccurate dosing.

4. A client is being prepared for discharge after a stroke. Which of the following interventions should be included in the discharge plan to prevent complications?

Correct answer: D

Rationale: The correct answer is to provide education on proper medication management. Proper medication management is crucial in reducing the risk of stroke recurrence and ensuring the client adheres to the treatment plan. While physical therapy, incentive spirometer use, and daily ambulation are important aspects of stroke rehabilitation, they are not directly related to preventing complications during the discharge phase.

5. A patient is admitted with signs of stroke. Which of the following diagnostic tests should the nurse anticipate as the priority?

Correct answer: A

Rationale: A CT scan is the priority diagnostic test to identify and confirm the location and severity of a stroke.

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