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
You, the nurse, have been monitoring the client with subcutaneous emphysema around the shoulder and lower neck. You notice that the area has expanded and is traveling up the neck. Based on your knowledge, what should the nurse anticipate doing in the near future?
Correct Answer: D
Rationale: The correct answer is D: Assisting with tracheostomy insertion. Subcutaneous emphysema traveling up the neck indicates potential airway compromise. Tracheostomy insertion may be necessary to secure the airway and prevent further complications. Surgery (choice A) may not address the immediate need for securing the airway. Encouraging the client to use the Incentive Spirometer (IS) (choice B) or palpating the area (choice C) would not address the urgency of the situation or provide a definitive solution to the airway compromise.
Question 3 of 5
A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?
Correct Answer: D
Rationale: The correct answer is D, Nonmaleficence. This principle emphasizes the obligation to do no harm to the patient. By discontinuing the experimental medication upon evidence of rapidly advancing kidney failure, the nurse is prioritizing the patient's well-being and preventing further harm. This decision aligns with the ethical duty to avoid causing harm to the patient. Now, let's analyze why the other choices are incorrect: A. Veracity: Veracity refers to truth-telling. Discontinuing the medication is not specifically related to truth-telling but rather to preventing harm. B. Autonomy: Autonomy relates to respecting the patient's right to make decisions about their care. Discontinuing the medication may be a decision made by the healthcare team based on patient safety, not necessarily the patient's autonomous choice. C. Fidelity: Fidelity involves being faithful and maintaining trust in the patient-nurse relationship. Discontinuing the medication can be seen as upholding fidelity by acting in the patient's
Question 4 of 5
A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse?
Correct Answer: C
Rationale: The correct answer is C. Transferring a client to the discharge location would be the lowest priority for the nurse during a disaster simulation. Priority should be given to immediate actions that ensure the safety and well-being of all clients. Here's a step-by-step rationale: 1. Preventing cross-contamination (choice A) is crucial to prevent the spread of the toxic substance. 2. Performing concise client assessment (choice B) is essential to identify and prioritize care for clients based on their needs. 3. Maintaining a client tracking system (choice D) is vital for ensuring accountability and continuity of care. 4. Transferring a client to the discharge location (choice C) can be delayed as it is not immediately life-threatening or crucial for the initial response.
Question 5 of 5
A nurse is planning client care for herself and an assistive personnel (AP). Which task should the nurse plan to perform?
Correct Answer: C
Rationale: The correct answer is C: Assessing a client's sacrum for edema. The nurse should plan to perform this task as it requires clinical judgment and assessment skills, which are within the scope of nursing practice. The nurse can identify early signs of skin breakdown and provide appropriate interventions. Explanation of other choices: A: Administration of an enema - This task can be safely delegated to an assistive personnel as long as the client's condition is stable. B: Application of antiembolic stockings - This task does not require clinical judgment and can be delegated to an assistive personnel. D: Assisting a client to cough and deep breathe - This task can be delegated to an assistive personnel as long as the client's condition is stable.