ATI RN
Client Safety Questions
Question 1 of 5
A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first?
Correct Answer: D
Rationale: The correct answer is D. The increase in the patient's temperature and dark urine could indicate a urinary tract infection (UTI), a common issue in older adults with indwelling catheters. The patient's confusion could be a sign of systemic infection. The RN should recommend a urine culture to confirm UTI and initiate appropriate treatment. A is incorrect because confusion in an older adult should not be dismissed without investigating the underlying cause. B is incorrect as increasing fluid intake may dilute the urine but does not address the potential infection. C is incorrect as the assessment findings are not normal and should not be ignored.
Question 2 of 5
Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS?
Correct Answer: B
Rationale: The correct answer is B: A synthetic surfactant. In ARDS, the alveoli become stiff and collapse, leading to impaired gas exchange. Synthetic surfactant helps reduce surface tension in the alveoli, improving lung compliance and gas exchange. Aminoglycoside antibiotics (A) are not typically used in ARDS. Potassium cation (C) is not a medication used to treat ARDS. Nonsteroidal anti-inflammatory drugs (D) do not address the underlying pathophysiology of ARDS.
Question 3 of 5
A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, how should the nurse position the patient?
Correct Answer: A
Rationale: The correct answer is A: On the left side. Placing the patient on the left side helps to improve ventilation-perfusion (V/Q) matching by allowing the unaffected left lung to expand fully. This position can help redistribute blood flow to the functioning lung, improving oxygenation. Choice B: On the right side would not be appropriate as it would further compromise the affected right lung. Choice C: In a reclining chair bed may not be ideal for promoting optimal lung expansion and V/Q matching. Choice D: Supine with the head of the bed elevated may not be as effective in improving V/Q matching compared to positioning on the left side.
Question 4 of 5
A patient is diagnosed with a large pulmonary embolism. When explaining to the patient what has happened to cause respiratory failure, which information will the nurse include?
Correct Answer: D
Rationale: The correct answer is D because in a large pulmonary embolism, a blood clot obstructs blood flow in the pulmonary arteries, leading to decreased blood flow to parts of the lungs despite adequate breathing. This mismatch between ventilation and perfusion causes respiratory failure. A is incorrect because thick membranes between air sacs and lung circulation do not play a significant role in pulmonary embolism. B is incorrect as it describes bronchial blockage, not pulmonary embolism. C is incorrect because it describes a mismatch in ventilation and perfusion but does not specifically relate to decreased blood flow due to a pulmonary embolism.
Question 5 of 5
When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patient's family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate?
Correct Answer: C
Rationale: Step-by-step rationale for the correct answer (C): 1. Urinary tract infection (UTI) triggers a systemic inflammatory response. 2. Systemic inflammation can lead to a condition called sepsis. 3. Sepsis can cause widespread inflammation in the body, including the lungs. 4. This generalized inflammation can result in damage to the lung tissue, leading to acute respiratory distress syndrome (ARDS). Summary of why other choices are incorrect: A: Incorrect because UTI does not directly spread to the lungs through circulation. B: Incorrect because toxins produced by UTI typically affect the urinary system, not the lungs. D: Incorrect because fever associated with infection does not directly cause scar tissue formation in the lungs.