ATI RN
ATI Capstone Comprehensive Assessment B
1. The nurse is performing hand hygiene before assisting a healthcare provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next?
- A. Repeat handwashing using antiseptic soap.
- B. Inform the healthcare provider and recruit another nurse to assist.
- C. Extend the handwashing procedure to 5 minutes.
- D. Rinse and dry hands and begin assisting the healthcare provider.
Correct answer: A
Rationale: The correct answer is A. The sink is considered a contaminated area. When hand hygiene is compromised during the process, it is essential to repeat handwashing using antiseptic soap to ensure proper hygiene. Choice B is incorrect because the situation can be managed by proper handwashing. Choice C is incorrect as extending the handwashing procedure to 5 minutes is not necessary in this scenario. Choice D is incorrect as the hands need to be properly cleaned before assisting the healthcare provider.
2. Which question is essential during screening for alcohol use disorder?
- A. What is your current employment status?
- B. Have you experienced any blackouts or loss of consciousness?
- C. Have you been sleeping well over the past month?
- D. Do you have a family history of substance use?
Correct answer: B
Rationale: The essential question during screening for alcohol use disorder is asking about blackouts or loss of consciousness, which can be indicative of excessive drinking and related to alcohol use disorder. Choices A, C, and D are not as directly related to screening for alcohol use disorder. Employment status (Choice A) is not a primary question in alcohol use disorder screening. Sleep quality (Choice C) and family history of substance use (Choice D) may be relevant but are not as crucial as inquiring about blackouts or loss of consciousness.
3. When caring for a patient with a colostomy, which nursing action is most important?
- A. Monitor the colostomy for signs of infection.
- B. Empty the colostomy bag when it is half full.
- C. Encourage the patient to eat smaller, more frequent meals.
- D. Apply a skin barrier to prevent irritation.
Correct answer: B
Rationale: Emptying the colostomy bag when it is half full is the most important nursing action when caring for a patient with a colostomy. This practice helps prevent leakage, reduces the risk of skin irritation, and promotes patient comfort. Monitoring for signs of infection (Choice A) is essential but not as crucial as maintaining proper colostomy care. Encouraging the patient to eat smaller, more frequent meals (Choice C) can be beneficial for colostomy patients but is not as critical as ensuring timely emptying of the colostomy bag. Applying a skin barrier to prevent irritation (Choice D) is important, but ensuring timely emptying of the colostomy bag takes precedence in preventing complications associated with a colostomy.
4. A nurse caring for a client under airborne precautions notes that the client is scheduled for a nuclear scan. What is the appropriate action for the nurse to take?
- A. Planning to have the nuclear scan performed at the bedside
- B. Calling the nuclear medicine department and telling the technician that the test will have to be delayed until airborne precautions have been discontinued
- C. Asking the technicians in the nuclear scan department to wear masks
- D. Placing a surgical mask on the client for transport and for contact with other individuals
Correct answer: D
Rationale: The correct action for the nurse is to place a surgical mask on the client for transport and for contact with other individuals when a patient under airborne precautions requires movement. This helps prevent the spread of infectious agents. Planning to have the nuclear scan at the bedside (Choice A) may not be feasible or appropriate. Calling the nuclear medicine department to delay the test (Choice B) may inconvenience the client and disrupt the scheduled procedure. Asking technicians in the nuclear scan department to wear masks (Choice C) does not provide adequate protection for others who may come into contact with the client outside the department.
5. 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.
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