ATI RN
Client Safety Questions
Question 1 of 5
A client's body uses physiologic mechanisms from within to respond to internal changes and maintain an essential balance. This process is known as:
Correct Answer: B
Rationale: The correct answer is B: homeostasis. Homeostasis refers to the body's ability to regulate internal conditions to maintain stability and balance. It involves various physiologic mechanisms such as temperature regulation, blood pressure control, and pH balance. Homeostasis is crucial for the body to function properly. A: Stress is a state of mental or emotional strain and is not the same as the body's internal balance regulation. C: Self-regulation is a broad term that can encompass various aspects of personal control and behavior, but it does not specifically refer to the body's physiological balance. D: Fight-or-flight response is a specific physiological response to perceived threats, not the overall process of maintaining internal balance.
Question 2 of 5
Upon skin inspection of an older adult, the coccyx wound is noted to be intact, reddened, and non-blanchable. What is the best way to document the nurse's assessment finding?
Correct Answer: A
Rationale: The correct way to document the nurse's assessment finding of an intact, reddened, and non-blanchable coccyx wound in an older adult is as a stage I pressure injury. A stage I pressure injury is characterized by intact skin with non-blanchable redness. In this case, the skin is intact, showing the initial signs of tissue damage due to pressure. Stages II, III, and IV pressure injuries involve more severe damage to the skin and underlying tissues. Stage II involves partial-thickness skin loss, stage III involves full-thickness skin loss, and stage IV involves full-thickness skin loss with extensive tissue necrosis. Since the coccyx wound is only showing redness without any loss of skin integrity, it aligns with a stage I pressure injury. Choices B, C, and D are incorrect as they describe more advanced stages of pressure injuries with skin breakdown, which is not present in this case.
Question 3 of 5
A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first?
Correct Answer: D
Rationale: The correct answer is D. The increase in the patient's temperature and dark urine could indicate a urinary tract infection (UTI), a common issue in older adults with indwelling catheters. The patient's confusion could be a sign of systemic infection. The RN should recommend a urine culture to confirm UTI and initiate appropriate treatment. A is incorrect because confusion in an older adult should not be dismissed without investigating the underlying cause. B is incorrect as increasing fluid intake may dilute the urine but does not address the potential infection. C is incorrect as the assessment findings are not normal and should not be ignored.
Question 4 of 5
A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Impaired vision. The patient's bifocal glasses indicate vision impairment, which is a significant fall risk factor as it affects depth perception and balance. This is evident as the patient experiences weakness in his legs when climbing stairs, which could be due to the visual impairment affecting his ability to judge distance and steps. The other choices are incorrect: Residence design (B) is not a factor since they live in a one-level ranch home; Blood pressure (C) is stable and not a fall risk factor in this case; Leg weakness (D) is a symptom of the patient's diabetes and could contribute to falls but is not the primary risk factor in this scenario.
Question 5 of 5
Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS?
Correct Answer: B
Rationale: The correct answer is B: A synthetic surfactant. In ARDS, the alveoli become stiff and collapse, leading to impaired gas exchange. Synthetic surfactant helps reduce surface tension in the alveoli, improving lung compliance and gas exchange. Aminoglycoside antibiotics (A) are not typically used in ARDS. Potassium cation (C) is not a medication used to treat ARDS. Nonsteroidal anti-inflammatory drugs (D) do not address the underlying pathophysiology of ARDS.