ATI RN
Client Safety in Nursing Questions
Question 1 of 5
A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate?
Correct Answer: B
Rationale: The correct answer is B: Endotracheal intubation and positive pressure ventilation. In hypercapnic respiratory failure, the patient's respiratory rate is low, indicating inadequate ventilation. The SpO2 of 89% and increasing lethargy suggest severe hypoxemia and impending respiratory failure. Endotracheal intubation allows for mechanical ventilation to improve oxygenation and ventilation. Positive pressure ventilation can help improve gas exchange and prevent further deterioration. A: Administration of 100% oxygen by non-rebreather mask would not address the underlying issue of inadequate ventilation in hypercapnic respiratory failure. C: Insertion of a mini-tracheostomy with frequent suctioning is not the initial intervention for managing hypercapnic respiratory failure. D: Initiation of bilevel positive pressure ventilation (BiPAP) may not be sufficient for this patient with impending respiratory failure; endotracheal intubation provides better control over ventilation and oxygenation.
Question 2 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 3 of 5
A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?
Correct Answer: D
Rationale: The correct answer is D. Nonmaleficence. The nurse is displaying the ethical principle of nonmaleficence by refusing to disclose the surgeon's medical diagnosis without permission. Nonmaleficence means to do no harm, and sharing sensitive medical information without consent could potentially harm the surgeon's privacy and confidentiality. A. Utility focuses on maximizing benefits and minimizing harm for the greater good, which is not directly related to the nurse's action in this scenario. B. Paternalism involves making decisions for a patient's best interest without their consent, which is not applicable here as the nurse is respecting the surgeon's autonomy. C. Justice refers to fairness and equal treatment, which is not the primary ethical principle being demonstrated in this situation.
Question 4 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 5 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.