ATI RN
Client Safety Basic Concept Template Questions
Question 1 of 5
A patient has a PaO2 of 50 mm Hg and a PaCO2 of 42 mm Hg because of an intrapulmonary shunt. Which therapy is the patient most likely to respond best to?
Correct Answer: A
Rationale: The correct answer is A: Positive pressure ventilation. Positive pressure ventilation helps improve oxygenation by increasing the mean airway pressure, which helps recruit collapsed alveoli and improve ventilation-perfusion matching in the presence of an intrapulmonary shunt. This therapy can effectively increase the PaO2 levels in this patient. Choice B: Oxygen administration at a FIO2 of 100% may not be sufficient to overcome the intrapulmonary shunt and improve oxygenation significantly. Choice C: Administration of O2 per nasal cannula at 1 to 3 L/min may not provide enough oxygen to overcome the shunting effect and improve oxygenation adequately. Choice D: Clearance of airway secretions with coughing and suctioning may be beneficial for airway clearance but is not directly related to correcting the underlying oxygenation issue caused by the intrapulmonary shunt.
Question 2 of 5
The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider?
Correct Answer: D
Rationale: The correct answer is D. A drop in SpO2 to 90% despite an increase in O2 flow rate indicates worsening respiratory status, which is a critical concern in a patient with aspiration pneumonia. This information is crucial to communicate to the healthcare provider for prompt intervention. Explanation: 1. SpO2 is a direct measure of oxygen saturation in the blood, indicating how well the patient is oxygenating. 2. A drop in SpO2 below 90% is concerning as it indicates hypoxemia and potential respiratory distress. 3. Despite increasing the O2 flow rate, the drop in SpO2 suggests that the patient's condition is deteriorating. 4. Prompt intervention is needed to prevent further respiratory compromise and potential respiratory failure. Summary: A: Productive cough with blood-tinged sputum may indicate lung infection, but it's not as critical as hypoxemia. B: Crackles throughout lung bases are common in pneumonia but don't directly indicate worsening respiratory status
Question 3 of 5
In ARDS, initially the patient experiences respiratory alkalosis due to the increased CO2 being expelled out from the increased respiratory rate. The nurse knows that which of the following factors contributes to the later signs of respiratory acidosis?
Correct Answer: B
Rationale: The correct answer is B: Hyaline membranes form which does not allow CO2 escape, increasing the CO2 concentration in the blood. Rationale: 1. In ARDS, damage to the alveoli leads to the formation of hyaline membranes. 2. These membranes impede gas exchange, particularly the elimination of CO2. 3. As CO2 accumulates in the blood, it leads to respiratory acidosis. 4. The other choices are incorrect as they do not directly relate to the impaired elimination of CO2, which is the key factor in causing respiratory acidosis in ARDS.
Question 4 of 5
You, the nurse, have been monitoring the client with subcutaneous emphysema around the shoulder and lower neck. You notice that the area has expanded and is traveling up the neck. Based on your knowledge, what should the nurse anticipate doing in the near future?
Correct Answer: D
Rationale: The correct answer is D: Assisting with tracheostomy insertion. Subcutaneous emphysema traveling up the neck suggests a potential airway compromise due to air leaking into surrounding tissues. Tracheostomy insertion may be necessary to establish a secure airway and prevent further complications. This intervention takes precedence over other options as it addresses the immediate threat to the client's airway and breathing. Options A, B, and C do not directly address the escalating subcutaneous emphysema and potential airway obstruction, making them less appropriate in this urgent situation.
Question 5 of 5
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Incident reports are used to document unexpected or adverse events. 2. A missing personal item, such as dentures, can impact a client's well-being. 3. It is essential to investigate and address the situation promptly. 4. Completing an incident report ensures proper documentation and follow-up. Summary of why other choices are incorrect: A. Identifying broken equipment is important but does not directly impact a client's safety or well-being. B. Staff attendance issues should be reported through appropriate channels but may not require an incident report. D. Disagreements with supervisors are common workplace issues but do not warrant an incident report unless they involve patient safety.