ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
Vesicle on the leg
Correct Answer: B
Rationale: The correct answer is B because a vesicle is a small fluid-filled blister on the skin. Vesicles are commonly caused by friction, burns, or insect bites, resulting in fluid accumulation beneath the skin. Pus is typically associated with larger, infected lesions such as pustules, not vesicles.
Choice C and D are likely incorrect as they do not provide relevant information or support for the appearance of a vesicle on the leg.
Question 2 of 5
The health-care provider ordered STAT arterial blood gases for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client without taking any action. The ABG results indicate a pH within the normal range (7.35-7.45), PaO2 is slightly lower than normal but still adequate for tissue oxygenation, PaCO2 is within the normal range (35-45), and HCO3 is normal (22-26). These values indicate that the client's acid-base balance is within normal limits, and no immediate intervention is needed. Encouraging deep breaths and coughing (
B) may be beneficial for some respiratory conditions but is not indicated here. Administering sodium bicarbonate IVP (
C) is unnecessary as the client's pH and HCO3 levels are normal. Notifying the respiratory therapist (
D) is not warranted since the ABG results do not indicate any acute respiratory distress. Monitoring the client (
A) is the appropriate action as the ABG results are stable.
Question 3 of 5
Subnormal core body temperature
Correct Answer: B
Rationale: The correct answer is B: Hypothermia. Subnormal core body temperature indicates the body temperature is below normal range, which is characteristic of hypothermia. Hyperthermia refers to elevated body temperature, making choice A incorrect.
Choices C and D are likely not provided as they do not directly relate to the concept of body temperature.
Question 4 of 5
Sleep comfort, wrong.
Correct Answer: A
Rationale: The correct answer is A: Make patient tired before sleeping. This is because physical and mental exhaustion can improve sleep quality. By engaging in activities that make the patient tired, such as exercise or mental stimulation, they are more likely to fall asleep faster and have a deeper, more restful sleep. Providing milk, as in choice B, may be relaxing for some individuals, but it is not a guaranteed method to improve sleep comfort.
Choice C and D are left blank, as they do not offer any relevant information related to improving sleep comfort.
Question 5 of 5
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety?
Correct Answer: B
Rationale: The correct answer is B: Note escalating behaviors and intervene immediately. This is the priority as the client is exhibiting signs of acute psychosis, indicating a risk to their safety. By noting escalating behaviors and intervening immediately, the nurse can prevent potential harm to the client or others.
Assessing for medication noncompliance (
Choice
A) is important but not the priority in this acute situation. Interpreting attempts at communication (
Choice
C) can be done after ensuring immediate safety. Assessing triggers for bizarre behaviors (
Choice
D) is not as urgent as intervening to prevent harm.