ATI PN COMMUNITY PROCTORED EXAM
(Detail Solutions)
1. The nurse is caring for a patient in labor and delivery. When near completing an
assessment of the patient’s cervix, the electronic infusion device is being used on the
intravenous (IV) infusion alarms. Which sequence of actions is most ap...
1. The nurse is caring for a patient in labor and delivery. When near completing an
assessment of the patient’s cervix, the electronic infusion device being used on the
intravenous (IV) infusion alarms. Which sequence of actions is most appropriate
for the nurse to take?
a. Complete the assessment, remove gloves, and silence the alarm.
Discontinue the assessment, silence the alarm, and assess the
b. intravenous site.
Complete the assessment, remove gloves, wash hands, and assess the
c. intravenous infusion.
Discontinue the assessment, remove gloves, use hand gel, and assess
d. the intravenous infusion.
ANS: C
Completing the assessment while wearing gloves, removing gloves, washing hands
after contact with body fluids, and then assessing the intravenous infusion will
assist in the prevention and transfer of any potential organisms to this intravenous
line. Completing the assessment, removing gloves, and silencing the alarm leaves
out the crucial step of decontaminating and washing the hands. Discontinuing the
assessment and assessing the IV leaves out removing the gloves and
decontamination, as well as completing the assessment for the patient.
Discontinuing the assessment, removing gloves, using hand gel, and assessing the
IV is incorrect because upon exposure to body fluids, washing hands is
appropriate.
2. The nurse is dressed and is preparing to care for a patient in the perioperative
area. The nurse has scrubbed hands and has donned a sterile gown and gloves.
Which action will indicate a break in sterile technique?
a. Touching clean protective eyewear
b. Standing with hands above waist area
c. Accepting sterile supplies from the surgeon
47
,d. Staying with the sterile table once it is open
ANS: A
Touching nonsterile (clean) protective eyewear once gowned and gloved with
sterile gown and gloves would indicate a break in sterile technique. Sterile
objects remain sterile only when touched by another sterile object. Standing
with hands folded on the chest is common practice and prevents arms and
hands from touching unsterile objects. Accepting sterile supplies from the
surgeon who has opened them with the appropriate technique is acceptable.
Staying with a sterile table once opened is a common practice to ascertain
that no one or nothing has contaminated the table.
3. The nurse is caring for a patient with an incision. Which actions will
best indicate an understanding of medical and surgical asepsis for a sterile
dressing change?
a. Donning clean goggles, gown, and gloves to dress the wound
b. Donning sterile gown and gloves to
remove the wound dressing Utilizing
clean gloves to remove the dressing
and sterile supplies for
c. the new dressing
Utilizing clean gloves to remove the dressing and clean supplies for
d. the new dressing
ANS: C
Utilize clean gloves (medical asepsis) to remove contaminated dressings and
sterile supplies, including gloves and dressings (surgical asepsis–sterile
technique) to reapply sterile dressings. Wearing sterile gowns and gloves is not
necessary when removing soiled dressings. Donning clean gloves to dress a
sterile wound would contaminate the sterile supplies. Utilizing clean supplies
for a sterile dressing would not help in decreasing the number of microbes at
the incision site.
4. The nurse is caring for a patient in the endoscopy area. The nurse observes
the technician performing these tasks. Which observation will require the
nurse to intervene?
a. Washing hands after removing gloves
b. Disinfecting endoscopes in the workroom 2
c. Removing gloves to transfer the endoscope
, d. Placing the endoscope in a container for transfer
ANS: C
Standard precautions are used to prevent and control the spread of infection.
Transferring contaminated equipment without the protection of gloves can
assist in the spread of microbes to inanimate objects and to the person doing
the transfer; therefore, the nurse must intervene. Utilizing gloves, washing
hands, covering contaminated supplies during transfer, and disinfecting
equipment in the appropriate way in the appropriate places utilize principles
of basic medical asepsis and standard precautions and can break the chain of
infection.
5. The nurse is caring for a patient who is at risk for infection. Which
action by the nurse indicates correct understanding about standard
precautions?
a. Teaches the patient about good nutrition
b. Dons gloves when wearing artificial nails
c. Disposes an uncapped needle in the designated container
d. Wears eyewear when emptying the urinary drainage bag
ANS: D
Standard precautions include the wearing of eyewear whenever there is a
possibility of a splash or splatter, like when emptying the urinary drainage
bag. Teaching the patient about good nutrition is positive but does not apply to
standard precautions. Standard precautions apply to contact with blood, body
fluid (except sweat),
nonintact skin, and mucous membranes from all patients. Artificial nails are not
worn when using standard precautions. Any needles should be disposed of
uncapped, or a mechanical safety device is activated for recapping.
6. The nurse is caring for a patient who has just delivered a neonate. The
nurse is checking the patient for excessive vaginal drainage. Which
precaution will the nurse use?
a. Contact
b. Droplet 3
c. Standard
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