ATI RN
Client Safety Questions
Question 1 of 5
A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
Correct Answer: D
Rationale: The correct answer is D: Presence of an ulnar pulse. The nurse should first assess the ulnar pulse because it indicates adequate circulation to the hand. If the ulnar pulse is absent, it suggests compromised blood flow, which could lead to ischemia or tissue damage. This assessment is crucial for ensuring the client's safety and preventing complications. Incorrect choices: A: Amount of pressure in fluid container - Monitoring pressure is important but not as critical as assessing circulation to the hand. B: Date of catheter tubing change - Important for infection prevention but not an immediate priority in this situation. C: Percent of heparin in infusion container - Heparin concentration is important but not as urgent as assessing circulation to the hand.
Question 2 of 5
Which statement should indicate to a nurse that an individual is experiencing a delusion?
Correct Answer: A
Rationale: The correct answer is A because it indicates a false belief that cannot be true (alien growing in liver). This is a classic example of a delusion, a fixed false belief. B is incorrect as it could be a hallucination seeing the dead husband. C is incorrect as it is a common fear, not a delusion. D is incorrect as it shows a sensory perception issue, not a delusion. Delusions are rigid, false beliefs that are not based in reality.
Question 3 of 5
A newly admitted client has taken thioridazine (Mellaril) for 2 years with good symptom control. Symptoms exhibited on admission included paranoid delusions and hallucinations. The nurse should recognize which potential cause for the return of these symptoms?
Correct Answer: C
Rationale: Rationale: Choice C is correct because not taking the medication as prescribed can lead to a return of symptoms. Missing doses or not taking it at the right time can result in a decrease in the drug's effectiveness. This can cause a relapse of symptoms like paranoid delusions and hallucinations. Incorrect Choices: A: Tolerance to the medication is unlikely after only 2 years of use. B: Taking the medication without food may affect absorption but is less likely to directly cause a return of symptoms. D: Combining alcohol with the medication can have adverse effects, but it is not the most likely reason for the return of symptoms in this case.
Question 4 of 5
The hormone used as a physiologic marker for stress is:
Correct Answer: B
Rationale: The correct answer is B: cortisol. Cortisol is known as the stress hormone because it is released in response to stress. It helps regulate various bodily functions during stressful situations. ADH (A) is antidiuretic hormone, involved in water balance. Estrogen (C) is a female sex hormone. Aldactone (D) is a medication used to treat high blood pressure and fluid retention, not a stress marker. Cortisol is the most appropriate choice as it directly correlates with stress response.
Question 5 of 5
What type of document states in writing the patient's healthcare choices or wishes if the person is unable?
Correct Answer: B
Rationale: The correct answer is B: Advanced care directive. This document allows individuals to outline their healthcare preferences in the event they are unable to communicate. It provides clear instructions on the type of care they wish to receive or refuse. Verbal consent (A) is temporary and may not accurately reflect long-term preferences. Durable power of attorney (C) designates a person to make healthcare decisions, but may not include specific preferences. Comfort measures only (CMO) order (D) is a medical directive for end-of-life care, not a comprehensive document like an advanced care directive.