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: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 of 5
If you are wearing gloves while providing care, hand hygiene is
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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.