ATI RN
Client Safety in Nursing Questions
Question 1 of 5
A Transatlantic flight exposes the body to natural radiation equivalent to exposure from
Correct Answer: B
Rationale: In the context of client safety in nursing, understanding the levels of radiation exposure is crucial for providing safe and effective care. In this question, the correct answer is B) A Chest x-ray. A chest x-ray exposes the body to a similar amount of radiation as a transatlantic flight due to the altitude at which airplanes fly, which increases exposure to cosmic radiation. The incorrect options can be explained as follows: A) A CT scan exposes the body to a much higher level of radiation compared to a transatlantic flight or a chest x-ray, making it an unsafe option. C) An abdominal x-ray typically exposes the body to a higher dose of radiation compared to a chest x-ray, thus posing a higher risk to the client. D) A lumbar X-ray also exposes the body to a higher amount of radiation compared to a chest x-ray, making it a less safe option in this scenario. Educationally, this question highlights the importance of understanding radiation exposure levels in various medical procedures and everyday situations. Nurses need to be aware of these risks to advocate for the safety of their clients and make informed decisions about diagnostic tests and treatments. By knowing the relative levels of radiation exposure, nurses can contribute to safer care practices and better outcomes for their clients.
Question 2 of 5
If you are wearing gloves while providing care, hand hygiene is
Correct Answer: A
Rationale: In the context of client safety in nursing, the correct answer to the question "If you are wearing gloves while providing care, hand hygiene is" is option A) mandatory. Hand hygiene is crucial in preventing the spread of infections in healthcare settings. Even when wearing gloves, healthcare providers must perform hand hygiene before and after glove use to ensure the highest level of protection for both themselves and their patients. Option B) stating that hand hygiene is optional is incorrect because gloves are not impermeable barriers and can still harbor bacteria and viruses. Therefore, proper hand hygiene is essential to prevent cross-contamination and infection transmission. Option C) forbidding and option D) encouraging are also incorrect as they do not accurately reflect the necessity of hand hygiene when wearing gloves in healthcare practice. In an educational context, it is vital to emphasize to nursing students the importance of hand hygiene even when gloves are worn. This practice reinforces infection control protocols and helps maintain a safe environment for patients. By understanding the rationale behind this concept, nursing students can develop good habits that will benefit both their practice and the well-being of those under their care.
Question 3 of 5
A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Stop the infusion of intravenous fluids. This is the appropriate action to take next because edema and tenderness above the IV site may indicate infiltration, where fluid leaks into the surrounding tissues. Stopping the infusion prevents further harm and allows assessment of the extent of infiltration. Applying cold compresses (A) or elevating the extremity (B) may provide some comfort but do not address the underlying issue. Flushing the catheter with normal saline (C) is not recommended in this situation as it could exacerbate the infiltration.
Question 4 of 5
A nurse is assessing a client diagnosed with paranoid schizophrenia. The nurse asks the client, "Do you receive special messages from certain sources, such as the television or radio?" Which potential symptom of this disorder is the nurse assessing?
Correct Answer: D
Rationale: The correct answer is D: Delusions of reference. The nurse is assessing the client's belief that external messages are specifically meant for them, a common symptom of paranoid schizophrenia. Thought insertion (A) refers to the belief that one's thoughts are not their own. Paranoid delusions (B) involve beliefs of harm or persecution. Magical thinking (C) is a belief in the power of unrelated actions to influence events. Delusions of reference (D) are the belief that neutral stimuli have personal significance. In this scenario, the nurse is specifically assessing the client's perception of external messages from the TV or radio, indicating delusions of reference.
Question 5 of 5
When assessing a client diagnosed with schizophrenia who takes an antipsychotic agent daily, which assessment finding should a nurse immediately report to the client's attending psychiatrist?
Correct Answer: C
Rationale: The correct answer is C: Temperature of 104°F (40°C). This finding indicates a potential fever, which could be a sign of a serious infection or other medical issue requiring immediate attention. Fever in a client with schizophrenia taking antipsychotic medication can be a sign of neuroleptic malignant syndrome (NMS), a rare but life-threatening side effect. A: Respirations of 22 beats/minute are within normal range. B: Weight gain of 8 pounds in 2 months may be concerning for metabolic side effects, but it is not an acute issue. D: Excessive salivation may be a side effect of the antipsychotic medication but is not as urgent as a high fever.