ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety?
Correct Answer: B
Rationale: The correct answer is B: Note escalating behaviors and intervene immediately. This is the priority as the client is exhibiting signs of acute psychosis, indicating a risk to their safety. By noting escalating behaviors and intervening immediately, the nurse can prevent potential harm to the client or others. Assessing for medication noncompliance (Choice A) is important but not the priority in this acute situation. Interpreting attempts at communication (Choice C) can be done after ensuring immediate safety. Assessing triggers for bizarre behaviors (Choice D) is not as urgent as intervening to prevent harm.
Question 2 of 5
A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?
Correct Answer: A
Rationale: Step 1: The charge nurse needs to address the issue directly and professionally with the staff nurse. Step 2: Statement A is the correct choice as it focuses on discussing unit expectations regarding delegation and task completion. Step 3: This approach promotes open communication, sets clear expectations, and provides an opportunity for improvement. Step 4: Option B is incorrect as it involves hearsay and does not address the issue directly. Step 5: Option C is not the best approach as it uses a threatening tone instead of fostering a constructive dialogue. Step 6: Option D is judgmental and accusatory, which can escalate the conflict instead of resolving it. Step 7: By choosing statement A, the charge nurse can effectively address the situation and guide the staff nurse towards better delegation and task completion practices.
Question 3 of 5
The health-care provider ordered STAT arterial blood gases for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client without taking any action. The ABG results indicate a pH within the normal range (7.35-7.45), PaO2 is slightly lower than normal but still adequate for tissue oxygenation, PaCO2 is within the normal range (35-45), and HCO3 is normal (22-26). These values indicate that the client's acid-base balance is within normal limits, and no immediate intervention is needed. Encouraging deep breaths and coughing (B) may be beneficial for some respiratory conditions but is not indicated here. Administering sodium bicarbonate IVP (C) is unnecessary as the client's pH and HCO3 levels are normal. Notifying the respiratory therapist (D) is not warranted since the ABG results do not indicate any acute respiratory distress. Monitoring the client (A) is the appropriate action as the ABG results are stable.
Question 4 of 5
A nurse on an obstetrics-gynecology unit is planning care for four clients after receiving change of shift report. Which of the following clients should the nurse assess first?
Correct Answer: D
Rationale: The correct answer is D because an ectopic pregnancy is a medical emergency that requires immediate assessment and intervention to prevent life-threatening complications. The nurse should prioritize assessing this client first to monitor for signs of rupture, such as severe abdominal pain and hypovolemic shock. Choice A is incorrect because although the client had a late term miscarriage, it is not an immediate emergency compared to an ectopic pregnancy. Choice B is incorrect as a bilateral tubal ligation is a routine surgical procedure with a lower risk of complications compared to an ectopic pregnancy. Choice C is incorrect as mastitis, while uncomfortable, is not as urgent as an ectopic pregnancy that requires immediate attention. In summary, the nurse should prioritize assessing the client admitted for an ectopic pregnancy first due to the potential life-threatening nature of the condition.
Question 5 of 5
In qualitative research, a guiding principle in deciding sample size is:
Correct Answer: C
Rationale: The correct answer is C: Data saturation. In qualitative research, data saturation is the point where new data no longer brings additional insights or changes in themes. This principle guides sample size determination as it ensures enough data is collected to reach this saturation point, leading to a comprehensive understanding of the phenomenon under study. Effect size (A) is more relevant in quantitative research, while the number of variables (B) and sub-group analysis (D) are factors that may influence the complexity of the study but are not directly related to determining sample size in qualitative research.