ATI Capstone Comprehensive Assessment B - Nurselytic

Correct Answer: C

Rationale: The correct answer is C. The nursing student washing her hands before glove removal after emptying a Foley bag indicates a need for further teaching. Hands should be washed after glove removal to maintain proper infection control.
Choice A is correct as wearing a gown when changing the bed of an incontinent client is a standard precaution.
Choice B is correct as washing hands before making contact with the client is a good practice.
Choice D is correct as changing gloves between tasks and procedures is a standard precaution to prevent the spread of infection.

Correct Answer: B

Rationale: The correct answer is to assist the patient to sit down slowly. This intervention is appropriate for a patient experiencing dizziness when standing up, as it helps prevent falls due to orthostatic hypotension. Encouraging deep breaths (
Choice
A) may not address the underlying cause of dizziness, which is related to postural changes. Instructing the patient to use a walker for support (
Choice
C) or teaching the patient how to change positions safely (
Choice
D) are not the most immediate and direct interventions to address the immediate risk of falling when feeling dizzy upon standing.

Correct Answer: B

Rationale: The correct answer is B. Proper documentation should include objective observations and detailed notes to ensure continuity of care.
Choice A is incorrect because incomplete entries can lead to gaps in information and compromise patient care.
Choice C is not completely accurate as corrections should be made in a manner that does not obscure the original entry but does not necessarily require a signature.
Choice D is incorrect as entries should ideally be corrected by the original author to maintain accountability and accuracy.

Correct Answer: A

Rationale: The most appropriate assessment question in this scenario is asking the patient, 'What activities, if any, has your pain prevented you from doing?' This question helps the healthcare provider understand how pain is impacting the patient's daily activities and mobility, providing valuable insight into the limitations caused by the pain.
Choice B focuses on pain medication effectiveness, which is not directly related to mobility assessment.
Choice C aims at pain intensity assessment but does not directly address mobility issues.
Choice D suggests a solution rather than gathering information about the current impact of pain on mobility.

Correct Answer: C

Rationale: Measuring the calf circumference of both legs is crucial when assessing for DVT in an immobile patient. A significant increase in the circumference of one calf compared to the other suggests the presence of a deep vein thrombosis. Option A is incorrect because rubbing the lower leg may dislodge a clot if present. Option B is incorrect as elastic stockings should not be removed frequently as this can increase the risk of clot formation. Option D is incorrect as dorsiflexing the foot can lead to pain and should not be done to assess for DVT.