ATI RN Fundamentals Online Practice 2023 B

ATI RN Fundamentals Online Practice 2023 B A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following actions by the newly licensed nurse requires intervention by the charge nurse? The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. The newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. The sterile field is positioned at the level of the newly licensed nurse's waist. - ANSWER Correct Answer: The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field. The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field. Incorrect Answer: The newly licensed nurse places sterile objects 2.5 cm (1 in) within the border of the field. The edges of the sterile field are considered contaminated. Therefore, the nurse should place all sterile items inside the 2.5 cm (1 in) border of the field. The newly licensed nurse holds the bottle of sterile saline outside the edge of the field when pouring. The newly licensed nurse should hold the bottle of sterile saline outside the edge of the field when pouring to prevent contaminating the field. The sterile field is positioned at the level of the newly licensed nurse's waist. An object that is below waist level is considered nonsterile. Positioning the table at waist level does not require intervention. A client demonstrates anger when the nurse does not respond within 5 min of ringing for the nurse. Which of the following is an appropriate response by the nurse? "I'm sorry, but another client needed my attention." "I could not arrive any sooner. What can I do for you?" "We had an emergency on the unit and that was a priority, but now I'm here." "That must be frustrating for you. How can I help you right now?" - ANSWER Correct Answer: "That must be frustrating for you. How can I help you right now?" This response is therapeutic because the nurse is acknowledging the client's feelings and offering help. Incorrect Answer: "I'm sorry, but another client needed my attention." This response is nontherapeutic because the nurse is responding defensively. "I could not arrive any sooner. What can I do for you?" This response is nontherapeutic because the nurse is responding defensively. "We had an emergency on the unit and that was a priority, but now I'm here." This response is nontherapeutic because the nurse is responding defensively. A home health nurse is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as potential indications of elder abuse? The caregiver is the client's financial power of attorney. The client is in a wheelchair with the wheels locked. The client reports receiving a full bath twice each week. The caregiver insists on remaining in the room. - ANSWER Correct Answer: The caregiver insists on remaining in the room. A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment. Incorrect Answer: The caregiver is the client's financial power of attorney. Having a caregiver who is the client's financial power of attorney allows the caregiver to perform necessary financial transactions on the client's behalf. This it is not an indication of elder abuse. The client is in a wheelchair with the wheels locked. If the client uses a wheelchair, it is important to lock the wheels when the client is stationary to keep the client safe. Locking the wheels of a wheelchair is not an indication of elder abuse. The client reports receiving a full bath twice each week. Neglect is a form of abuse or mistreatment that is characterized by omission of necessary care. Although hygiene is an important part of care for all clients, a full bath is not necessary every day for older adults due to the adverse effects it can have on fragile skin. Therefore, a full bath twice each week is sufficient for effective care and is not an indication of neglect or elder abuse.