which of the following procedures always requires surgical asepsis
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Nursing Elites

ATI RN

ATI Fundamentals Proctored Exam 2024

1. Which of the following procedures always requires surgical asepsis?

Correct answer: B

Rationale: Surgical asepsis, which involves maintaining a sterile field and preventing contamination in a surgical setting, is required for urinary catheterization as it involves entering a sterile body cavity. Vaginal instillation of conjugated estrogen, nasogastric tube insertion, and colostomy irrigation do not always require surgical asepsis as they involve different levels of sterility and infection control measures.

2. When a client is comatose and has advance directives stating a desire to avoid life-sustaining measures, but the family wants these measures, what action should the nurse take?

Correct answer: Arrange for an ethics committee meeting to address the family's concerns.

Rationale: In this scenario, the nurse should prioritize the client's wishes as outlined in the advance directives. By arranging for an ethics committee meeting, the nurse can facilitate discussions between the family and healthcare team to ensure that the client's wishes are respected while addressing the concerns of the family. This approach promotes ethical decision-making and collaborative communication among all involved parties, ultimately aiming to provide the best possible care for the client while considering their autonomy and preferences.

3. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?

Correct answer: B: Nurse to interpret

Rationale: In situations where there is a language barrier between healthcare providers and patients, it is essential to ensure accurate communication. Using professional interpreter services is the most appropriate choice to ensure clear and precise communication. Relying on the client's children for interpretation may not guarantee accurate or confidential communication. Asking the nurse to interpret can lead to miscommunication or misunderstanding of important medical information. Providing translation services for a nominal fee to clients may not always be feasible or culturally appropriate. Regularly evaluating the client's understanding helps ensure that information is effectively communicated and comprehended.

4. When planning care for a client with severe acute respiratory distress syndrome (SARS), which of the following actions should not be included in the care plan?

Correct answer: Administer antibiotics

Rationale: Severe acute respiratory distress syndrome (SARS) is caused by a virus, not bacteria, and antibiotics are ineffective against viral infections. Therefore, administering antibiotics would not be appropriate in the care plan for a client with SARS. The priority interventions for SARS include providing supplemental oxygen to improve oxygenation, administering antiviral medications to target the viral infection, and using bronchodilators to help with bronchospasm or airway constriction. Antibiotics are not indicated unless there is a secondary bacterial infection present.

5. A client experiencing dyspnea will receive continuous oxygen. Which oxygen device should be used to deliver a precise amount of oxygen?

Correct answer: B: Venturi mask

Rationale: A Venturi mask is the most appropriate choice for delivering a precise amount of oxygen to a client with dyspnea. Unlike other oxygen delivery devices, the Venturi mask allows for accurate oxygen concentration delivery by controlling the amount of air entrained. This feature is crucial in ensuring the client receives the prescribed oxygen concentration, especially in cases where precise oxygen delivery is required.

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