ATI RN
Client Safety Nursing Skill Template Questions
Question 1 of 5
A family has recently immigrated to the United States. All members are quickly learning the language and the children are all in public school. Both parents are working and adapting to the new culture. What is this family demonstrating?
Correct Answer: B
Rationale: The correct answer is B: Cultural assimilation. This family is actively adapting to the new culture by learning the language, enrolling children in public school, and adjusting to the work environment. Cultural assimilation involves integrating into a new culture while retaining some aspects of the original culture. This family is not experiencing culture shock (A) because they are gradually adjusting, not in a state of distress. They are not displaying cultural blindness (C) as they are aware of and adapting to the new culture. Lastly, cultural imposition (D) refers to forcing one's own culture onto others, which is not the case here.
Question 2 of 5
A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to:
Correct Answer: C
Rationale: The correct answer is C: Call adult protective services because you suspect elder mistreatment. In this scenario, the patient's presentation raises concerns for elder abuse, as evidenced by the presence of a stage 3 pressure ulcer, old bruising, and the patient's unkempt appearance. By involving adult protective services, the nurse can initiate an investigation to ensure the safety and well-being of the patient. This step is crucial in addressing potential abuse and protecting the vulnerable adult. Summary: A: Calling social services for nursing home placement is premature without investigating the suspected abuse. B: Asking the son to step out may not address the potential abuse and could hinder the assessment. D: While assessing cognitive status is important, addressing suspected elder mistreatment takes precedence in this situation.
Question 3 of 5
The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: The correct answer is C. Assess the respiratory status and pulse oximeter reading. This is the first intervention the nurse should implement because it provides crucial information about the client's current oxygenation status and respiratory function. By assessing these parameters, the nurse can quickly identify any immediate issues that may require intervention, such as respiratory distress or hypoxemia. Confirming ventilator settings (A) and verifying ventilator alarms (B) are important tasks but assessing the client's respiratory status takes priority as it directly impacts the client's oxygenation and ventilation. Monitoring arterial blood gas results (D) is important for evaluating the effectiveness of ventilation but is not the first step in managing a client on a ventilator.
Question 4 of 5
When the V/Q lung scan result returns with a mismatch ratio that is greater than 1, which condition should be suspected?
Correct Answer: C
Rationale: The correct answer is C: Pulmonary embolus. A V/Q lung scan is used to evaluate the ventilation-perfusion ratio in the lungs. A mismatch ratio greater than 1 indicates a significant ventilation-perfusion mismatch, which is commonly seen in pulmonary embolism where there is a blockage in the pulmonary artery. This leads to decreased perfusion in areas of the lung, causing the mismatch. Therefore, when the mismatch ratio is greater than 1, pulmonary embolus should be suspected. Choices A, B, and D do not directly correlate with a mismatch ratio on a V/Q lung scan, making them incorrect in this context.
Question 5 of 5
Which physiological mechanism primarily contributes to hypoxemia in ARDS?
Correct Answer: B
Rationale: The correct answer is B, impaired gas exchange due to alveolar-capillary membrane damage. In ARDS, inflammation and injury to the alveolar-capillary membrane lead to increased permeability and fluid accumulation, impairing gas exchange. Reduced hemoglobin levels (choice A) do not directly cause hypoxemia in ARDS. Decreased perfusion to pulmonary capillaries (choice C) may contribute to hypoxemia but is not the primary mechanism in ARDS. Increased airway resistance due to bronchoconstriction (choice D) affects ventilation, not gas exchange, and is not the primary cause of hypoxemia in ARDS.