which factor places a patient at the highest risk for infection

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment A

1. Which factor places a patient at the highest risk for infection?

A. A healthy immune system
B. Presence of chronic illness
C. Being well-nourished
D. Age over 65 years

Correct answer: B

Rationale: The presence of chronic illness is the factor that places a patient at the highest risk for infection. Chronic illness can compromise the immune system's ability to fight off infections effectively, making individuals more susceptible to getting sick. Option A, a healthy immune system, actually reduces the risk of infection. Option C, being well-nourished, can support overall health but does not directly correlate with infection risk. While age over 65 years is a risk factor for certain infections due to age-related immune system changes, chronic illness has a more significant impact on infection risk.

2. A patient on mechanical ventilation experiences a sudden drop in oxygen saturation. What should the nurse check first?

A. Check the ventilator tubing for disconnection.
B. Increase the patient's oxygen flow.
C. Perform a full physical assessment.
D. Reassess the patient's oxygen levels after 5 minutes.

Correct answer: A

Rationale: The correct answer is to check the ventilator tubing for disconnection first when a patient on mechanical ventilation experiences a sudden drop in oxygen saturation. This is crucial because equipment malfunction, such as tubing disconnection, can lead to decreased oxygen delivery, resulting in a drop in oxygen saturation. Checking the tubing ensures that the ventilation system is functioning properly and that the patient is receiving the necessary oxygen. Option B is incorrect because increasing oxygen flow without checking for equipment issues may not address the root cause of the drop in saturation. Option C is not the priority in this situation as the immediate focus should be on assessing and ensuring the functioning of the ventilation equipment. Option D delays addressing the potential equipment malfunction, which could worsen the patient's condition if not promptly resolved.

3. After signing an informed consent form, a client states, 'I have changed my mind and do not want to have the procedure.' Which of the following actions should the nurse take?

A. Suggest that family members discuss the importance of the surgery with the client
B. Notify the surgeon that the client wishes to withdraw informed consent for the procedure
C. Document the risks of refusing the procedure in the client's medical record
D. Discuss the benefits of the procedure with the client

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to notify the surgeon that the client wishes to withdraw informed consent for the procedure. This ensures that the client's right to refuse treatment is respected. Choice A is incorrect because involving family members in this decision could violate the client's autonomy. Choice C is incorrect as it does not address the immediate need to respect the client's decision. Choice D is also incorrect as the client has clearly stated their refusal of the procedure.

4. A client is being taught about which foods to include in a low fiber diet. Which statement indicates understanding?

A. Choosing a fresh pear would be a good snack option
B. I should make refried beans for supper
C. Selecting white rice as a side dish is a good choice
D. Opting for bran cereal would be a good breakfast choice

Correct answer: C

Rationale: The correct answer is C because white rice is a low-fiber food suitable for a low-fiber diet, making it an appropriate choice. Choices A, B, and D are incorrect because fresh pear, refried beans, and bran cereal are high-fiber foods and not suitable for a low-fiber diet.

5. Which action by a nurse demonstrates effective communication with a patient?

A. Providing the patient with written information about their care.
B. Maintaining eye contact and listening actively to the patient.
C. Using medical jargon to explain the patient's condition.
D. Speaking with the patient in a hurried manner to save time.

Correct answer: B

Rationale: Maintaining eye contact and actively listening to the patient is crucial in effective communication as it helps build rapport, shows empathy, and ensures that the patient feels heard and understood. Providing written information can be helpful, but the direct interaction is essential for effective communication. Using medical jargon may confuse the patient instead of clarifying their condition. Speaking hurriedly can make the patient feel rushed and not valued, hindering effective communication.