the nurse is observing a family member changing a dressing for a patient in the home health environment which observation indicates the family member
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. The family member is observing a family member changing a dressing for a patient in the home health environment. Which observation indicates the family member has a correct understanding of how to manage contaminated dressings?

Correct answer: B

Rationale: The correct way to manage contaminated dressings is to place them in plastic bags for proper disposal. This helps prevent the spread of infection. Choice A is incorrect because saving part of the dressing is not a recommended practice. Choice C is not directly related to managing contaminated dressings. Choice D is incorrect as wrapping the used dressing in toilet tissue is not the appropriate way to dispose of contaminated dressings.

2. A patient is receiving a blood transfusion and develops chills, a headache, and low back pain. What is the nurse’s priority action?

Correct answer: B

Rationale: The correct answer is to stop the transfusion (Choice B). The symptoms described - chills, headache, and low back pain - are indicative of a transfusion reaction. The priority action is to immediately stop the transfusion to prevent further complications such as more severe reactions like hemolytic reactions or anaphylaxis. Administering acetaminophen (Choice A) may help with symptoms but does not address the underlying cause. Slowing the transfusion rate (Choice C) may not be sufficient if a serious transfusion reaction is occurring. Administering antihistamines (Choice D) is not the priority in this situation; stopping the transfusion takes precedence to ensure patient safety.

3. How should a nurse respond to a client with terminal cancer who has requested a change in the level of pain medication?

Correct answer: B

Rationale: The correct answer is to consult with the healthcare provider to adjust the medication. It is crucial for the healthcare provider to be involved in changing pain medication for a client with terminal cancer to ensure that the new dosage is appropriate and safe. Option A is incorrect because adjusting medication without consulting the healthcare provider can be dangerous and is not within the scope of the nurse's practice. Option C is incorrect because ignoring the client's request goes against the principles of patient-centered care. Option D is incorrect as the primary goal should be to provide effective pain relief with the appropriate dosage, not to increase the medication arbitrarily.

4. A charge nurse is discussing HIPAA with a newly licensed nurse. Which of the following actions should the charge nurse include in the teaching as an example of a HIPAA violation?

Correct answer: D

Rationale: The correct answer is D. Emailing client information through an unencrypted server is a HIPAA violation because it can lead to data breaches. Choices A, B, and C do not violate HIPAA. Posting the name of the nurse providing care on a client's communication board does not disclose sensitive health information. Discussing the client's new medication with a hospital pharmacist is a routine healthcare practice. Faxing requested medical information for a client who is transferring to another facility is a secure way to transmit healthcare data.

5. A healthcare professional is preparing to administer an intravenous (IV) medication. What action should the healthcare professional take to ensure patient safety?

Correct answer: B

Rationale: Verifying the patient's identity using two identifiers is crucial to ensure the right patient receives the right medication. This process helps prevent medication errors by confirming the patient's identity through at least two unique identifiers, such as name, date of birth, or medical record number. Choice A is not directly related to ensuring patient safety during medication administration. Choice C is incorrect as medications should be prepared in a sterile environment, not just at the healthcare professional's station. Choice D is not a safe practice as medications should be administered at the scheduled time to maintain therapeutic effectiveness.

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