ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with
Correct Answer: D
Rationale: The correct answer is D, inserting a pulmonary artery catheter. This is the most appropriate action to differentiate between ARDS and pulmonary edema caused by left ventricular failure. The pulmonary artery catheter can provide valuable information such as pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac output. In ARDS, the pulmonary artery pressure and pulmonary capillary wedge pressure are typically low, whereas in pulmonary edema due to left ventricular failure, these pressures are elevated. Positioning the patient for a chest radiograph (A) would provide anatomical information but not differentiate between ARDS and pulmonary edema. Drawing blood for arterial blood gases (B) can provide information on oxygenation but may not be sufficient to differentiate between the two conditions. Obtaining a ventilation-perfusion scan (C) is not typically used to differentiate between ARDS and pulmonary edema.
Question 2 of 5
A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?
Correct Answer: C
Rationale: The correct answer is C: Review the events leading up to each medication administration error. This strategy is the most critical initial step in addressing medication administration errors. By conducting a thorough review of the events leading up to each error, the committee can identify root causes and contributing factors, allowing for targeted interventions to prevent similar errors in the future. This approach aligns with the principles of continuous quality improvement (CQI) by focusing on understanding the underlying issues before implementing solutions. Choice A: Providing an inservice on medication administration to all nurses may be beneficial, but without understanding the specific factors contributing to errors, the impact may be limited. Choice B: Requiring staff nurses to pass a medication administration examination focuses on individual competency, which is important but not as effective as addressing system issues that contribute to errors. Choice D: Developing a quality improvement program for nurses involved in errors is necessary but should come after identifying and addressing the root causes of errors through a comprehensive review process.
Question 3 of 5
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first?
Correct Answer: C
Rationale: The correct answer is C: Place in respiratory/secretion precautions. This is the priority because meningococcal meningitis is spread through respiratory secretions, so isolating the child will prevent transmission. A: Institute seizure precautions is important but not the first priority. B: Monitoring neurologic status is essential but not the initial action. D: Administering antibiotics is crucial, but isolating the child to prevent spread takes precedence.
Question 4 of 5
Within how many feet of oxygen administration is smoking not allowed?
Correct Answer: B
Rationale: The correct answer is B: 12 feet. This distance is established to prevent fires as oxygen supports combustion. Smoking within 12 feet of oxygen administration poses a significant fire hazard. Choice A (4 meters) is incorrect as it is greater than 12 feet. Choices C and D are incorrect as they do not provide a specific distance requirement.
Question 5 of 5
The health-care provider ordered STAT arterial blood gases for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client without taking any action. The ABG results indicate a pH within the normal range (7.35-7.45), PaO2 is slightly lower than normal but still adequate for tissue oxygenation, PaCO2 is within the normal range (35-45), and HCO3 is normal (22-26). These values indicate that the client's acid-base balance is within normal limits, and no immediate intervention is needed. Encouraging deep breaths and coughing (B) may be beneficial for some respiratory conditions but is not indicated here. Administering sodium bicarbonate IVP (C) is unnecessary as the client's pH and HCO3 levels are normal. Notifying the respiratory therapist (D) is not warranted since the ABG results do not indicate any acute respiratory distress. Monitoring the client (A) is the appropriate action as the ABG results are stable.