ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
A nurse is planning client care for herself and an assistive personnel (AP). Which task should the nurse plan to perform?
Correct Answer: C
Rationale: The correct answer is C: Assessing a client's sacrum for edema. The nurse should plan to perform this task as it requires clinical judgment and assessment skills, which are within the scope of nursing practice. The nurse can identify early signs of skin breakdown and provide appropriate interventions. Explanation of other choices: A: Administration of an enema - This task can be safely delegated to an assistive personnel as long as the client's condition is stable. B: Application of antiembolic stockings - This task does not require clinical judgment and can be delegated to an assistive personnel. D: Assisting a client to cough and deep breathe - This task can be delegated to an assistive personnel as long as the client's condition is stable.
Question 2 of 5
After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with
Correct Answer: D
Rationale: The correct answer is D, inserting a pulmonary artery catheter. This is the most appropriate action to differentiate between ARDS and pulmonary edema caused by left ventricular failure. The pulmonary artery catheter can provide valuable information such as pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac output. In ARDS, the pulmonary artery pressure and pulmonary capillary wedge pressure are typically low, whereas in pulmonary edema due to left ventricular failure, these pressures are elevated. Positioning the patient for a chest radiograph (A) would provide anatomical information but not differentiate between ARDS and pulmonary edema. Drawing blood for arterial blood gases (B) can provide information on oxygenation but may not be sufficient to differentiate between the two conditions. Obtaining a ventilation-perfusion scan (C) is not typically used to differentiate between ARDS and pulmonary edema.
Question 3 of 5
Within how many feet of oxygen administration is smoking not allowed?
Correct Answer: B
Rationale: The correct answer is B: 12 feet. This distance is established to prevent fires as oxygen supports combustion. Smoking within 12 feet of oxygen administration poses a significant fire hazard. Choice A (4 meters) is incorrect as it is greater than 12 feet. Choices C and D are incorrect as they do not provide a specific distance requirement.
Question 4 of 5
A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?
Correct Answer: C
Rationale: The correct answer is C: Review the events leading up to each medication administration error. This strategy is the most critical initial step in addressing medication administration errors. By conducting a thorough review of the events leading up to each error, the committee can identify root causes and contributing factors, allowing for targeted interventions to prevent similar errors in the future. This approach aligns with the principles of continuous quality improvement (CQI) by focusing on understanding the underlying issues before implementing solutions. Choice A: Providing an inservice on medication administration to all nurses may be beneficial, but without understanding the specific factors contributing to errors, the impact may be limited. Choice B: Requiring staff nurses to pass a medication administration examination focuses on individual competency, which is important but not as effective as addressing system issues that contribute to errors. Choice D: Developing a quality improvement program for nurses involved in errors is necessary but should come after identifying and addressing the root causes of errors through a comprehensive review process.
Question 5 of 5
After an explosion at a factory one of the employees approaches the nurse and says 'I am an unlicensed assistive personnel (UAP) at the local hospital.' Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers?
Correct Answer: C
Rationale: The correct answer is C: Palpate pulses. This task should be assigned first because assessing the pulses can provide crucial information about the injured workers' circulation and perfusion status. By palpating pulses, the unlicensed assistive personnel can quickly identify any signs of compromised circulation or potential life-threatening conditions. This immediate assessment is essential for prioritizing care and determining the urgency of further interventions. Other choices are incorrect because: A: Getting temperatures can be important but not as immediately critical as assessing pulses for circulatory status. B: Taking blood pressure may provide valuable information, but assessing pulses gives a more direct indication of perfusion. D: Checking alertness is important, but assessing pulses should be the priority for immediate life-saving interventions.