which action by the nurse demonstrates effective infection control measures

ATI RN

ATI Capstone Comprehensive Assessment B

1. Which action by the nurse demonstrates effective infection control measures?

A. Perform hand hygiene before and after patient contact.
B. Wear gloves when administering medications.
C. Dispose of used equipment in designated containers.
D. Wear a mask when interacting with the patient.

Correct answer: A

Rationale: The correct answer is A: Perform hand hygiene before and after patient contact. Effective hand hygiene is a fundamental infection control measure that helps prevent the spread of pathogens. Wearing gloves when administering medications (choice B) is important for protecting both the patient and the nurse but is not a direct demonstration of infection control. Disposing of used equipment in designated containers (choice C) is more related to proper waste management than infection control. Wearing a mask when interacting with the patient (choice D) is essential in certain situations, but hand hygiene is a more universal and critical practice for infection control.

2. A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

A. Hold the cane with your left hand
B. Move the cane forward 18 inches with each step
C. When walking, move your left foot forward first
D. Keep your elbow straight when you hold the cane

Correct answer: C

Rationale: The correct instruction for a client with left-sided weakness using a cane is to move the left foot forward first. This technique helps improve stability and safety by ensuring weight-bearing on the stronger side while providing support with the cane. Choice A is incorrect because the cane should be held on the stronger side, which is the right side in this case. Choice B is incorrect as the recommended distance to move the cane forward with each step is about 6 inches, not 18 inches. Choice D is incorrect as it is essential to maintain a slight bend in the elbow while using the cane to absorb shock and provide flexibility.

3. A nurse is providing home care for a client who is receiving tube feedings and medication through a gastrostomy tube. The family member providing the feedings reports that the client has begun to have diarrhea. For which of the following practices should the nurse intervene?

A. Cleanse the bag every 24 hours
B. Cleanse the bag every 48 hours
C. Use tap water
D. Flush the tube every 4 hours

Correct answer: A

Rationale: The correct answer is A. Cleansing the bag every 24 hours can lead to contamination, increasing the risk of infection and diarrhea. Using tap water (choice C) is not recommended for cleaning the gastrostomy tube due to the risk of introducing harmful microorganisms. Cleansing the bag every 48 hours (choice B) is not frequent enough and may also contribute to infection. Flushing the tube every 4 hours (choice D) is a standard practice to ensure patency and should not be intervened by the nurse.

4. A patient reports nausea and vomiting after chemotherapy. What is the nurse's priority action?

A. Administer an antiemetic as prescribed.
B. Encourage the patient to eat small, frequent meals.
C. Provide the patient with anti-nausea wristbands.
D. Encourage the patient to rest after eating.

Correct answer: A

Rationale: The correct answer is to administer an antiemetic as prescribed. Chemotherapy-induced nausea and vomiting can be distressing for patients. Administering an antiemetic helps alleviate these symptoms effectively. Choice B, encouraging the patient to eat small, frequent meals, may be helpful for other gastrointestinal issues but is not the priority when the patient is experiencing nausea and vomiting. Choice C, providing anti-nausea wristbands, may offer some relief but is not as direct and immediate as administering an antiemetic. Choice D, encouraging the patient to rest after eating, is not the priority in this situation where the focus should be on managing the nausea and vomiting.

5. What is a key characteristic of Illness Anxiety Disorder?

A. Excessive focus on minor symptoms without medical evidence of illness
B. The need for consistent reassurance from healthcare professionals
C. Compulsive behavior to avoid physical illness
D. Development of avoidance behaviors to reduce anxiety

Correct answer: A

Rationale: The correct answer is A: "Excessive focus on minor symptoms without medical evidence of illness." Illness Anxiety Disorder, formerly known as hypochondriasis, is characterized by a preoccupation with having a serious illness despite no medical evidence to support the presence of an illness. Individuals with this disorder often interpret normal bodily sensations as signs of severe illness. Choice B is incorrect because while individuals with Illness Anxiety Disorder may seek reassurance from healthcare professionals, the excessive focus on minor symptoms is the key characteristic. Choice C is incorrect as compulsive behaviors to avoid physical illness are more characteristic of illnesses like Obsessive-Compulsive Disorder. Choice D is incorrect as the development of avoidance behaviors to reduce anxiety is more commonly seen in conditions like specific phobias or social anxiety disorder.