ATI RN
Client Safety Nursing Skill Template Questions
Question 1 of 5
A patient with ARDS is receiving mechanical ventilation with high PEEP levels. What should the nurse prioritize monitoring to detect complications?
Correct Answer: B
Rationale: The correct answer is B: Cardiac output and blood pressure. In ARDS patients on high PEEP, monitoring cardiac output and blood pressure is crucial due to the risk of hemodynamic compromise. High PEEP can decrease venous return, leading to decreased cardiac output and hypotension. Monitoring these parameters helps detect and prevent complications like hypotension, which can further compromise oxygenation. Choice A is incorrect because while monitoring respiratory rate and depth is important in ARDS, the priority in this scenario is monitoring hemodynamic status due to the potential impact of high PEEP on cardiac function. Choice C is incorrect as monitoring white blood cell count is not directly related to complications of high PEEP in ARDS patients. Choice D is incorrect because sputum production and characteristics are not the priority for monitoring in this scenario; cardiac output and blood pressure are more critical indicators of potential complications.
Question 2 of 5
A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement?
Correct Answer: D
Rationale: The correct answer is D: End tidal CO2 monitoring. This is the first assessment of tube placement because it provides immediate feedback on the effectiveness of ventilation. End tidal CO2 monitoring measures the amount of CO2 exhaled, indicating proper placement in the airway. If the tube is correctly positioned, CO2 will be detected. Chest X-Ray (A) is not immediate and delays intervention. Auscultation (B) may not always confirm placement. Pulse oximetry (C) can be misleading as oxygen saturation can be maintained even with incorrect tube placement.
Question 3 of 5
A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directives. Which of the following statements by the client indicates a need for clarification?
Correct Answer: C
Rationale: The correct answer is C because the statement indicates a misunderstanding of health care proxy selection. A person can choose anyone, not just a family member, as their health care proxy. Statement A is correct as a health care proxy can be changed at any time. Statement B is also correct as the proxy makes end-of-life decisions when the person is incapacitated. Statement D is correct as the health care proxy only comes into effect when the person is unable to make decisions.
Question 4 of 5
A nurse has been reassigned from her regular area of work to a unit that is short staffed. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Rationale: - A. Asking what she will be assigned to do first helps the nurse clarify her responsibilities and prioritize tasks effectively. - B. Determining skills can wait until knowing the assigned tasks. - C. Identifying options is not urgent compared to knowing immediate tasks. - D. Notifying the manager can be done after understanding her duties. Summary: The nurse should first ask about her assignment to understand her immediate responsibilities before assessing her skills or considering other options.
Question 5 of 5
A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication?
Correct Answer: B
Rationale: The correct answer is B: Nonmaleficence. Nonmaleficence is the ethical principle that emphasizes the duty to do no harm to the patient. In this situation, by not administering the pain medication, the nurse is ensuring that the client is not being harmed or hastened towards death. Administering the medication would be to alleviate suffering, not to hasten death. A: Utilitarianism focuses on maximizing overall good for the majority. In this case, it could be argued that administering the medication would provide the greatest good for the client, but it does not directly address the concern of potentially hastening death. C: Fidelity pertains to being faithful to commitments and maintaining trust. While important, it does not directly address the immediate ethical dilemma of administering pain medication in this situation. D: Veracity relates to truthfulness and honesty. While crucial in communication with the client, it is not the primary ethical principle to consider in this specific scenario.