ATI RN
Client Safety in Nursing Questions
Question 1 of 5
A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Stop the infusion of intravenous fluids. This is the appropriate action to take next because edema and tenderness above the IV site may indicate infiltration, where fluid leaks into the surrounding tissues. Stopping the infusion prevents further harm and allows assessment of the extent of infiltration. Applying cold compresses (A) or elevating the extremity (B) may provide some comfort but do not address the underlying issue. Flushing the catheter with normal saline (C) is not recommended in this situation as it could exacerbate the infiltration.
Question 2 of 5
When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, which assessment finding should a nurse immediately report to the client's attending psychiatrist?
Correct Answer: C
Rationale: The correct answer is C: Temperature of 104°F (40°C). This finding indicates a potential fever, which could be a sign of a serious infection or other medical issue requiring immediate attention. Fever in a client with schizophrenia taking antipsychotic medication can be a sign of neuroleptic malignant syndrome (NMS), a rare but life-threatening side effect. A: Respirations of 22 beats/minute are within normal range. B: Weight gain of 8 pounds in 2 months may be concerning for metabolic side effects, but it is not an acute issue. D: Excessive salivation may be a side effect of the antipsychotic medication but is not as urgent as a high fever.
Question 3 of 5
You are a nurse working in the college student health center. You receive a call that an athlete has been injured. The athlete's physiologic response would be:
Correct Answer: B
Rationale: The correct answer is B: an increased heart rate. When an individual is injured, their sympathetic nervous system is activated, causing an increase in heart rate to supply more oxygen and nutrients to the injured area. This response helps the body prepare for fight or flight. A: an increased appetite is incorrect because injury typically suppresses appetite due to stress and pain. C: a decrease in perspiration is incorrect because the body often responds to stress or injury by increasing perspiration to help regulate body temperature. D: a decrease in respiratory rate is incorrect because injury or stress typically leads to an increase in respiratory rate to meet the body's increased oxygen demand.
Question 4 of 5
What must the nurse consider ethically, morally, and professionally when a terminally ill client asks for assistance with death?
Correct Answer: B
Rationale: The correct answer is B: ANA Code of Ethics for Nurses. This code provides guidance on ethical considerations for nurses, including the duty to respect human dignity and promote patients' autonomy. It specifically addresses end-of-life decisions and emphasizes the nurse's role in supporting the client's wishes while upholding ethical standards. Choices A, C, and D are incorrect because the Medical Code of Ethics, state boards of nursing, and facility protocols may not specifically address the ethical considerations surrounding end-of-life care for terminally ill clients. Nurses should adhere to the ANA Code of Ethics to ensure they are making ethical, moral, and professional decisions in such sensitive situations.
Question 5 of 5
What action should the nurse take immediately after instilling the prescribed eyedrops into the patient's eye?
Correct Answer: A
Rationale: The correct action is to press gently on the inner canthus area immediately after instilling eyedrops. This helps prevent systemic absorption of the medication and reduces the risk of side effects. Pressing on the inner canthus area also prevents drainage of the medication into the nasolacrimal duct, ensuring maximum efficacy. Choice B is incorrect as wiping the eyelid toward the inner canthus can cause the medication to be wiped away before it has a chance to be absorbed. Choice C is incorrect as applying a sterile eye patch is unnecessary and can lead to ocular irritation. Choice D is incorrect as maintaining light pressure on the lower eyelid can cause the medication to be squeezed out of the eye prematurely.