which of the following statements reflect the principles of sterile technique
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. Which of the following statements reflects the principles of sterile technique?

Correct answer: A

Rationale: The correct statement reflecting the principles of sterile technique is that sterile objects that come in contact with unsterile objects are considered contaminated. This principle is crucial in maintaining asepsis during medical procedures. Choice B is incorrect because items in a sterile package should only be used if they remain sterile; opening the package does not automatically contaminate the items. Choice C is incorrect as any part of a sterile field that hangs below the top of the table is considered unsterile. Choice D is incorrect as the edge of a sterile field and a border inward are typically considered unsterile to maintain the integrity of the sterile area.

2. A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: Performing a bladder scan is the first step to assess bladder retention before any further interventions.

3. Which of the following is an adverse effect of Lithium Carbonate that requires client education?

Correct answer: B

Rationale: The correct answer is B: Gastrointestinal distress. When taking Lithium Carbonate, clients may experience gastrointestinal distress as an adverse effect. It is crucial to educate clients about this potential side effect to help them manage it effectively. Choices A, C, and D are incorrect. Increased risk of infection (Choice A) is not a typical adverse effect of Lithium Carbonate. Similarly, increased white blood cell count (Choice C) is not associated with this medication's adverse effects. Nausea and vomiting (Choice D) are general side effects of many medications but are not specifically attributed to Lithium Carbonate.

4. What are the nursing considerations when caring for a patient with chronic obstructive pulmonary disease (COPD)?

Correct answer: A

Rationale: The correct answer is A. Pursed-lip breathing is a nursing consideration for patients with COPD as it helps improve oxygenation and reduces air trapping. While administering bronchodilators and corticosteroids (choice B) is part of the treatment plan, it is typically done by healthcare providers. Monitoring oxygen saturation and arterial blood gases (ABGs) (choice C) is important but not a direct nursing consideration. Teaching the patient how to use an inhaler (choice D) is relevant but not specific to COPD care.

5. What are the clinical signs of hyperglycemia in a patient with diabetes mellitus, and how should a nurse respond?

Correct answer: B

Rationale: The correct signs of hyperglycemia in a patient with diabetes mellitus are polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). These symptoms indicate high blood sugar levels. Therefore, the correct response for a nurse would be to recognize these signs, monitor blood glucose levels, and administer insulin to manage the hyperglycemia. Choice A is incorrect because it only addresses the response aspect without mentioning the signs. Choices C and D are incorrect as they do not reflect the classic clinical signs of hyperglycemia in diabetes mellitus.

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