ATI RN
Essentials Of Nursing Client Safety Questions
Question 1 of 5
A patient with ARDS is placed on low tidal volume ventilation. What is the primary benefit of this strategy?
Correct Answer: B
Rationale: The correct answer is B: To minimize the risk of barotrauma and volutrauma. Low tidal volume ventilation in ARDS reduces the risk of lung injury by decreasing the pressure and volume delivered to the lungs, thus lowering the chances of barotrauma (lung injury from high pressure) and volutrauma (lung injury from excessive volume). This strategy helps protect the fragile alveoli, prevents further damage, and improves outcomes. Choice A is incorrect because low tidal volume ventilation does not directly prevent fluid accumulation in the alveoli. Choice C is incorrect because it focuses on carbon dioxide elimination, which is not the primary goal of low tidal volume ventilation in ARDS. Choice D is incorrect because although improving perfusion in dependent lung areas is important, it is not the primary benefit of low tidal volume ventilation in ARDS.
Question 2 of 5
Which intervention is key to preventing ventilator-associated pneumonia as a complication in a patient with acute respiratory distress syndrome (ARDS)?
Correct Answer: C
Rationale: Rationale for Choice C: Providing frequent mouth care and oral hygiene is key to preventing ventilator-associated pneumonia in ARDS patients. This intervention helps reduce the risk of oral bacteria entering the lungs, which can lead to pneumonia. Maintaining oral hygiene also decreases the colonization of pathogens in the oropharynx, reducing the risk of aspiration. This intervention is supported by evidence-based practice guidelines for preventing ventilator-associated pneumonia. Summary of other choices: A: Scheduled prophylactic nasopharyngeal suctioning is not recommended as a routine preventive measure for ventilator-associated pneumonia in ARDS patients. B: Instilling normal saline down the endotracheal tube can increase the risk of infection and does not address the root cause of ventilator-associated pneumonia. D: Using high tidal volumes on the ventilator can exacerbate lung injury in ARDS patients and is not a preventive measure for ventilator-associated pneumonia.
Question 3 of 5
You are precepting a nursing student who is assisting you care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is:
Correct Answer: D
Rationale: Correct Answer: D Rationale: 1. Positive End-Expiratory Pressure (PEEP) helps open collapsed alveoli by maintaining pressure in the lungs during exhalation. 2. In ARDS, alveoli collapse, leading to ventilation-perfusion mismatch and hypoxemia. 3. By applying PEEP, alveoli are kept open, improving oxygenation and lung compliance. 4. Option A is incorrect as PEEP doesn't directly assist with breathing in and out or improve airflow. 5. Option B is incorrect as PEEP can affect cardiac output but the primary goal is to recruit collapsed alveoli. 6. Option C is incorrect as PEEP doesn't specifically prevent fluid from filling alveoli but rather helps with lung recruitment.
Question 4 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. The nurse should explain the risks the client faces if she leaves the facility with a high INR level of 3.5 while on warfarin. This is important because a high INR puts the client at risk for bleeding, which can be life-threatening. By explaining the risks, the nurse is providing the client with crucial information to help her make an informed decision about leaving against medical advice. Choice A is incorrect because forcing the client to sign an AMA form may not be legally appropriate if the client has decision-making capacity. Choice B is incorrect because threatening the client with insurance consequences is not ethical and does not address the immediate health risk. Choice D is incorrect because involving security is not necessary in this situation and does not address the client's medical needs.
Question 5 of 5
A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicates which of the following?
Correct Answer: B
Rationale: Rationale for Correct Answer B: The nurse's signature on the consent form confirms the client appears competent to provide consent. This is important as it ensures the client has the capacity to make informed decisions about their care. The nurse assesses the client's ability to understand the information provided regarding the procedure and its risks and benefits. By signing as a witness, the nurse acknowledges that the client is mentally competent to provide consent. Summary of Incorrect Choices: A: Incorrect. The nurse's signature does not determine if the client has a mental illness. This falls under the purview of the healthcare provider, not the nurse. C: Incorrect. While the nurse may have explained the risks and benefits, this is not the sole purpose of the nurse's signature on the consent form. D: Incorrect. The nurse's signature does not indicate the client's spouse agrees with the procedure; this is not the nurse's role in the consent process.