ATI RN
Client Safety Questions
Question 1 of 5
A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who had an indwelling urinary catheter removed 5 hours ago and has not voided first. This is because urinary retention can lead to complications like urinary tract infection or bladder distention. It is important to monitor and address this promptly to prevent further issues. A: While a green gastric aspirate with a pH of 5.3 may indicate potential issues, it is not as urgent as urinary retention. C: A capillary refill time of 4 seconds in a client with COPD is concerning but does not require immediate attention compared to urinary retention. D: Fruity breath odor in a client with late-stage cirrhosis may indicate hepatic encephalopathy, which is serious, but urinary retention takes precedence due to the risk of immediate complications.
Question 2 of 5
A nurse is preparing to witness informed consent for a client who is preoperative. The client asks the nurse, 'Are there other options besides surgery?' Which of the following responses should the nurse make?
Correct Answer: C
Rationale: Rationale for correct answer (C): 1. The nurse should promote client autonomy and informed decision-making. 2. Asking if the client has discussed other treatments shows respect for client preferences. 3. It encourages the client to consider all options before making a decision. 4. This response supports the client in making an informed choice based on available treatments. Summary of incorrect choices: A: Incorrect because it dismisses the client's question and rushes the consent process. B: Incorrect as it imposes the nurse's opinion on the client, which is not appropriate. D: Incorrect because it assumes the client does not want surgery without exploring other options.
Question 3 of 5
The parents of a toddler being treated for pesticide poisoning ask: 'Why is activated charcoal used? What does it do?'
Correct Answer: A
Rationale: The correct answer is A because activated charcoal works by adsorbing toxins in the stomach, preventing their absorption into the bloodstream. This helps decrease the body's absorption of the poison. Choice B is incorrect because charcoal does not form a compound with the poison. Choice C is incorrect because activated charcoal does not help to remove the poison from the body but rather prevents its absorption. Choice D is incorrect because it does not accurately describe the mechanism of action of activated charcoal in binding toxins. Overall, choice A is the most precise and scientifically accurate explanation of activated charcoal's function in cases of poisoning.
Question 4 of 5
Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
Correct Answer: A
Rationale: The correct answer is A because Shigella is a highly contagious bacterial infection that can easily spread in the community. Infants are more vulnerable to severe complications from Shigella. Reporting this case promptly to the public health department can help prevent further spread of the infection. Choice B is incorrect because the presence of acid-fast bacillus smear does not necessarily indicate a communicable disease that requires immediate public health intervention. Choice C is incorrect because Pneumocystis carinii is an opportunistic infection typically seen in immunocompromised individuals, and while important for the individual's treatment, it does not pose an immediate public health threat. Choice D is incorrect because varicella zoster virus causes chickenpox and shingles, which are not reportable diseases to the public health department unless there is an outbreak situation.
Question 5 of 5
A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?
Correct Answer: D
Rationale: The correct answer is D: Nonmaleficence. The nurse is displaying the ethical principle of nonmaleficence by respecting the surgeon's right to privacy and confidentiality. By not disclosing the surgeon's medical diagnosis, the nurse is avoiding causing harm or breaching the surgeon's trust. A: Utility focuses on maximizing benefits and minimizing harm for the greater good. B: Paternalism involves making decisions for others based on what is believed to be in their best interest. C: Justice pertains to fairness and equality in healthcare decision-making.