the nurse is performing hand hygiene before assisting a health care provider with insertion of a chest tube while washing hands the nurse touches the
Logo

Nursing Elites

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?

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. A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

Correct answer: C

Rationale: The correct instruction the nurse should include is to advise the client to drink four to five glasses of water daily. Increasing water intake helps alleviate constipation by softening stool and increasing bowel movements. Choice A, increasing dietary intake of raw vegetables, can be helpful in preventing constipation but may not be sufficient as the sole intervention for someone already experiencing constipation. Choice B, limiting activity, can worsen constipation as physical activity helps stimulate bowel movements. Choice D, bearing down hard when defecating, can lead to other issues like hemorrhoids and should be avoided.

3. A nurse witnesses a colleague administering the wrong IV solution to a client. What should the nurse do first?

Correct answer: B

Rationale: The correct first step for the nurse to take in this situation is to ask the colleague if they intend to report the error. It is important to address the error promptly and directly with the colleague involved to ensure that the appropriate actions are taken to correct the mistake and prevent harm to the client. Completing an incident report, calling the healthcare provider, or notifying the supervisor can be done after discussing the error with the colleague. Immediate communication with the colleague directly involved in the error is crucial to address the situation effectively.

4. A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings indicates the client might be experiencing an acute hemolytic reaction?

Correct answer: C

Rationale: Chills and fever are classic signs of an acute hemolytic reaction, where the body is reacting to the transfused blood. This reaction can be life-threatening and requires immediate intervention. Low back pain, distended neck veins, and headache are not typical signs of an acute hemolytic reaction. Low back pain may be associated with kidney issues, distended neck veins with fluid overload or heart failure, and headache with various causes such as stress, dehydration, or migraines.

5. A nurse is observing a nursing student practicing standard precautions. Which observation by the instructor indicates that further teaching is necessary?

Correct answer: D

Rationale: The correct answer is D because touching a patient's skin with sterile gloves compromises the sterility of the gloves, increasing the risk of contamination. Choices A, B, and C demonstrate correct practices in standard precautions. Wearing gloves when changing bed linens and to remove a wound dressing, as well as washing hands after removing gloves, are all appropriate and necessary steps to prevent the spread of infection.

Similar Questions

Which nursing action will best help a patient with diabetes manage their condition?
A nurse manager notes that a nurse is not following safety protocols. What should the manager do first?
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?
What are the complications of diabetes mellitus that a nurse should monitor for?
A client undergoing surgery refuses to remove religious jewelry. What is the best course of action?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses