A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?

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PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN Questions

Question 1 of 5

A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?

Correct Answer: B

Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.

Question 2 of 5

A client is found on the floor of their room experiencing a seizure. Which action is the nurse's priority?

Correct Answer: B

Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration of fluids or secretions. Restraint should never be used during a seizure as it can cause harm to the client. Performing a neurological assessment is important but not the immediate priority during an active seizure. While monitoring vitals is essential, ensuring the client's airway is clear takes precedence.

Question 3 of 5

A nurse is providing discharge teaching for a client who is postop following abdominal surgery. Which of the following behaviors should the nurse identify as increasing the client's risk for complications?

Correct Answer: C

Rationale: The correct answer is C. Suppression of the urge to defecate postoperatively can lead to complications such as constipation, which can increase the risk of complications after abdominal surgery. Walking twice daily (choice A) is actually beneficial for preventing complications such as deep vein thrombosis. Suppression of the urge to cough (choice B) can lead to issues like atelectasis. Lack of ambulation (choice D) can also contribute to complications like pneumonia and blood clots.

Question 4 of 5

A nurse is reviewing the medication class, benzodiazepines. The nurse would use caution when administering benzodiazepines to which of the clients below?

Correct Answer: A

Rationale: Benzodiazepines can increase intraocular pressure, which is why they must be used cautiously in patients with glaucoma. In clients with this condition, benzodiazepines can potentially worsen symptoms and lead to further complications involving the eyes. Therefore, administering benzodiazepines to a client with glaucoma should be done with caution. Choices B, C, and D are not directly contraindicated with benzodiazepines, making them less likely to cause harm compared to administering to a client with glaucoma.

Question 5 of 5

A nurse is caring for a client prescribed the HMG CoA reductase inhibitor, atorvastatin. Which of the following should be monitored while this medication is prescribed?

Correct Answer: A

Rationale: Corrected Rationale: Atorvastatin, an HMG CoA reductase inhibitor, can lead to hepatotoxicity. Therefore, monitoring liver function through regular tests is essential. Baseline liver function should be assessed, followed by tests at 12 weeks after starting therapy and periodically thereafter. This monitoring helps detect early signs of liver damage, including jaundice, nausea, and dark urine. Incorrect Choices Rationale: B) Renal function test is not directly affected by atorvastatin. C) Hearing screenings and D) Visual acuity screenings are not indicated for monitoring while on atorvastatin therapy.

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