ATI PN LEADERSHIP MANAGEMENT PROCTORED EXAM

ATI PN LEADERSHIP MANAGEMENT PROCTORED EXAM 2020 1. The nurse is participating in a “time-out.” In which activities will the nurse be involved? (Select all that apply.) a. Verify the correct site. b. Verify the correct patient. c. Verify the correct procedure. d. Perform “time-out” after surgery. e. Perform the actual marking of the operative site. ANS: A, B, C A time-out is performed just before starting the procedure for final verification of the correct patient, procedure, site, and any implants. The marking and time-out most commonly occur in the holding area, just before the patient enters the OR. The individual performing surgery and who is accountable for it must personally mark the site, and the patient must be involved if possible. 2. The nurse is using a forced air warmer for a surgical patient preoperatively. Which goals is the nurse trying to achieve? (Select all that apply.) a. Induce shivering. b. Reduce blood loss. c. Induce pressure ulcers. d. Reduce cardiac arrests. e. Reduce surgical site infection. ANS: B, D, E Evidence suggests that pre-warming for a minimum of 30 minutes may reduce the occurrence of hypothermia. Prevention of hypothermia (core temperature 36° C) helps to reduce complications such as shivering, cardiac arrest, blood loss, SSI, pressure ulcers, and mortality. 3. The nurse is caring for a postoperative patient with an incision. Which actions will the nurse take to decrease wound infections? (Select all that apply.) a. Maintain normoglycemia. b. Use a straight razor to remove hair. c. Provide bath and linen change daily. d. Perform first dressing change 2 days postoperatively. e. Perform hand hygiene before and after contact with the patient. f. Administer antibiotics within 60 minutes before surgical incision. ANS: A, E Performing hand hygiene before and after contact with the patient helps to decrease the number of microorganisms and break the chain of infection. Maintaining blood glucose levels at less than 150 mg/dL has resulted in decreased wound infection. Removing unwanted hair by clipping instead of shaving decreases the numbers of nicks and cuts caused by a razor and the potential for the introduction of microbes. The patient is postoperative; administration of an antibiotic 60 minutes before the surgical incision supports the defense against infection preoperatively. Providing a bath and linen change daily is positive but is not necessarily important for infection control. Many surgeons prefer to change surgical dressings the first time so they can inspect the incisional area, but this is done before 2 days postoperatively. 4. A nurse is assigned the following four clients for the current shift. Which of the following clients should the nurse assess first? A. A client who has a hip fracture and is in Buck’s traction B. A client who has aspiration pneumonia and a respiratory rate of 28/min C. A client who has diabetes mellitus stage 2 pressure ulcer on his foot D. A client who has a C diff infection and needs a stool specimen collected 5. A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nurse take? A. Notify the nursing supervisor about the issues B. Contact the client’s physical therapist C. Apply a warm compress to the hip D. Reposition the client for comfort 6. The mother of a client with breast cancer states, it’s been hard for her, especially after losing her hair. And it has been difficult to pay for all the treatments. Which of the following actions is appropriate client advocacy? A. The nurse investigates potential resources to help the client purchase wig B. The nurse explains to the mother that most clients with cancer lose their hair C. The nurse informs the next shift nurse regarding the mother’s concerns. D. The nurse suggests counseling for the client’s body image issues.