what is the most important nursing action when caring for a patient with a central venous catheter cvc
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. What is the most important nursing action when caring for a patient with a central venous catheter (CVC)?

Correct answer: B

Rationale: The most important nursing action when caring for a patient with a central venous catheter (CVC) is to change the CVC dressing every 72 hours. This practice reduces the risk of infection and ensures the catheter remains secure. Monitoring the patient's blood pressure regularly is important but not the most crucial action when managing a CVC. Flushing the CVC with normal saline is essential but not the most important action. Avoiding using the CVC for blood draws is a good practice, but it is not the most critical nursing action in this scenario.

2. After a case manager completes a history and physical assessment for a client with COPD, which of the following actions should the case manager take next?

Correct answer: A

Rationale: After completing a history and physical assessment for a client with COPD, the next step for the case manager should be to call the provider with a list of client concerns. This is crucial as the provider needs to be informed about any issues or changes in the client's health status to ensure appropriate management. Identifying the client's current health needs, as mentioned in option B, is important but would typically follow after communicating the client's concerns to the provider. Compiling a list of community resources (option C) and referring the client to a COPD support group (option D) are also valuable actions but are not the immediate next steps after completing the assessment.

3. 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?

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.

4. A nurse manager is discussing electronic medical records with a newly licensed nurse. Which of the following actions should the nurse take to maintain client confidentiality?

Correct answer: A

Rationale: The correct answer is A: Log out of the computer terminal before leaving. Logging out before leaving the computer terminal is crucial to ensuring patient data remains confidential and to prevent unauthorized access. Choice B is incorrect because sharing passwords compromises confidentiality. Choice C is incorrect as changing passwords regularly, although a good practice for security, is not directly related to maintaining client confidentiality. Choice D is incorrect as it does not address the immediate concern of maintaining client confidentiality through proper access to electronic medical records.

5. What is the nurse's priority intervention for a patient who has developed a pressure ulcer?

Correct answer: B

Rationale: The correct answer is to reposition the patient every 2 hours. Repositioning helps prevent the worsening of pressure ulcers by relieving pressure on affected areas and promoting blood circulation, which aids in healing. Applying a dressing (choice A) is important but not the priority compared to repositioning. Providing pain medication (choice C) is essential for comfort but does not address the root cause of the pressure ulcer. Cleaning the ulcer with normal saline (choice D) is part of wound care but does not take precedence over repositioning to prevent further tissue damage.

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