ATI RN
Client Safety in Nursing Questions
Question 1 of 5
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action?
Correct Answer: A
Rationale: The correct answer is A: Perform endotracheal intubation and initiate mechanical ventilation. In ARDS, nonrebreather mask may not provide adequate oxygenation due to severe lung damage. Intubation and mechanical ventilation can provide higher levels of oxygen and positive end-expiratory pressure to improve oxygenation. CPAP (choice B) may not be sufficient for severe cases of ARDS. Administering furosemide (Lasix) (choice C) is not appropriate for poor oxygenation in ARDS. Calling a code for respiratory arrest (choice D) is premature and not indicated unless the patient's condition deteriorates to that extent.
Question 2 of 5
A nurse in an acute care setting is serving on a committee whose charge is to use the auditing process to client care. Which of the following aspects of client care is measured by a process audit?
Correct Answer: C
Rationale: Step 1: Process audits focus on evaluating the procedures and processes involved in providing care. Step 2: Quality of nursing care provided is directly related to the processes and procedures followed by nursing staff. Step 3: By conducting a process audit, the committee can assess if the established procedures are being followed to ensure quality care. Step 4: Availability of resources and nursing staff ratios are important but are more related to structural or outcome audits. Step 5: Length of facility stay for a cohort of clients is an outcome measure and not directly related to the process of providing care. Summary: The correct answer is C because process audits assess the quality of care provided through evaluating the procedures followed, while the other choices are not directly related to the processes of care provision.
Question 3 of 5
A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, 'The doctor didn't tell me I was supposed to receive an enema.' Which of the following nursing actions is appropriate at this time?
Correct Answer: A
Rationale: Correct Answer: A. Check the client's medical record for the provider's prescription. Rationale: 1. Verifying the provider's prescription is essential to ensure the client's safety and adherence to medical orders. 2. It is crucial to confirm the medical necessity before proceeding with the procedure. 3. Checking the medical record respects the client's right to informed consent and promotes patient-centered care. Summary: - Option B does not address the importance of verifying the provider's prescription. - Option C assumes the client's comfort with the procedure without confirming the doctor's order. - Option D prematurely escalates the situation without confirming the medical necessity.
Question 4 of 5
A charge nurse receives complaints about an LPN's lack of care. What should the charge nurse do?
Correct Answer: C
Rationale: The correct answer is C because talking with the clients who reported concerns allows the charge nurse to gather direct feedback and specific details about the LPN's behavior, which can help in understanding the situation better and addressing the issues effectively. By speaking with the clients, the charge nurse can assess the validity of the complaints and take appropriate action, such as providing additional training or supervision to the LPN. Reviewing the personnel file (A) may provide background information but does not address the current complaints directly. Discussing with other nurses (B) may lead to gossip or bias without evidence from the clients. Reassigning client care (D) without addressing the root cause is not a sustainable solution.
Question 5 of 5
A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C: Explain the risk the client faces if she leaves the facility. Rationale: 1. Warfarin is a blood thinner that requires close monitoring of the INR to prevent complications like bleeding. 2. An INR of 3.5 is above the therapeutic range, putting the client at risk for bleeding. 3. It is crucial for the nurse to educate the client about the potential consequences of leaving against medical advice. 4. By explaining the risks, the nurse can help the client make an informed decision about their health. 5. This action demonstrates the nurse's duty to ensure the client's safety and well-being. Summary of other choices: A: Forcing the client to sign an AMA form does not address the client's concerns or provide necessary education about the risks. B: Threatening the client with insurance consequences is coercive and does not prioritize the client's health. D: Involving security is not appropriate in this situation and does not address the client