ATI RN
Essentials Of Nursing Client Safety Questions
Question 1 of 5
A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C. The nurse should explain the risks the client faces if she leaves the facility with a high INR level of 3.5 while on warfarin. This is important because a high INR puts the client at risk for bleeding, which can be life-threatening. By explaining the risks, the nurse is providing the client with crucial information to help her make an informed decision about leaving against medical advice. Choice A is incorrect because forcing the client to sign an AMA form may not be legally appropriate if the client has decision-making capacity. Choice B is incorrect because threatening the client with insurance consequences is not ethical and does not address the immediate health risk. Choice D is incorrect because involving security is not necessary in this situation and does not address the client's medical needs.
Question 2 of 5
A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency.
Correct Answer: D
Rationale: Correct Answer: D (Rescue the clients) Rationale: In a fire emergency, the top priority is to ensure the safety of individuals by rescuing them. Once the clients are safe, the nurse can proceed to other steps like pulling the fire alarm, confining the fire, and extinguishing it. By rescuing the clients first, the nurse minimizes the risk of harm and ensures everyone's safety. Summary of Incorrect Choices: A (Pull the fire alarm): While important, pulling the fire alarm should come after rescuing the clients to alert others and initiate the fire safety protocol. B (Confine the fire): Confining the fire is crucial but should be done after ensuring everyone's safety through rescue. C (Extinguish the fire): Extinguishing the fire is essential, but it should not be the first step as the priority is to rescue individuals from harm.
Question 3 of 5
A nurse is delegating morning vital signs to an assistive personnel (AP). What action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B because determining the time frame for reporting results is crucial in ensuring timely and effective communication of vital signs data. This step allows the nurse to promptly address any abnormal findings or changes in the patient's condition. A: Verifying the AP's educational preparation is important but not directly related to delegating morning vital signs. C: Observing the AP obtaining vital signs can be helpful for initial training but may not be necessary for every instance of delegation. D: Asking the AP to take vital signs of a post-surgery client first is not the most appropriate action as prioritization should be based on patient acuity, not the type of surgery.
Question 4 of 5
An assistive personnel (AP) tells the nurse manager that she observed a nurse on the unit removing a small amount of morphine from syringes prior to administering the medication to clients. Which of the following actions should the nurse manager take first?
Correct Answer: A
Rationale: The correct answer is A: Gather data about the nurse's work performance and attendance history. This is the first step because it allows the nurse manager to assess the situation comprehensively before taking any action. By gathering data, the nurse manager can determine the extent of the issue, whether it is an isolated incident or a pattern of behavior. This information will help in making an informed decision on how to proceed. Approaching the nurse (B) directly may not be appropriate without first understanding the full context of the situation. Notifying the risk manager (C) is premature without knowing the full extent of the issue. Referring the nurse to the board of nursing diversion program (D) should only be considered after gathering all relevant information about the nurse's actions.
Question 5 of 5
An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?
Correct Answer: C
Rationale: The correct answer is C because as an RN, the responsibility should be assumed for the client who is actively dying and requires IV pain medication. This client's condition is critical and requires the expertise and assessment skills of an RN to manage pain effectively. RNs have the knowledge and training to administer IV medications safely and to monitor the client's response closely. Choices A, B, and D can be safely managed by other team members such as LPNs or assistive personnel, as they do not require the specialized skills and assessment capabilities of an RN for immediate care.