ATI RN
Client Safety Nursing Skill Template Questions
Question 1 of 5
An older adult client has been moved from home to a skilled nursing facility (SNF). Which behavior, demonstrated by this client, indicates a problem with daily functioning?
Correct Answer: D
Rationale: The correct answer is D because refusing to use the prescribed walker indicates a problem with mobility and safety, which are crucial aspects of daily functioning for an older adult. This behavior can lead to an increased risk of falls and injury. A: Eating 80% of meals shows the client's ability to engage in self-care. B: Watching television with others is a social activity and does not necessarily indicate a problem with daily functioning. C: Wanting to wear one's own clothing is a personal preference and does not directly affect daily functioning. In summary, answer choice D is correct because it directly impacts the client's ability to function independently and safely, while the other choices are less critical in determining daily functioning issues.
Question 2 of 5
Which of the following client situation is appropriate to delegate to a (n) unlicensed assistive personnel (UAP)? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A because assisting a client with a 1:1 feeding is within the scope of practice for unlicensed assistive personnel (UAP). UAPs can provide basic assistance with feeding under the supervision of a licensed nurse. This task does not require specialized nursing skills. Choice B is incorrect because emptying a foley catheter drainage bag involves a sterile procedure that should be performed by a licensed nurse. Choice C is incorrect as assessing a client with new onset shortness of breath and taking vital signs requires critical thinking and clinical judgment, which are beyond the scope of practice for UAPs. Choice D is incorrect because providing information about discharge home health services involves patient education and coordination of care, which are responsibilities of the licensed nurse or healthcare provider.
Question 3 of 5
A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to:
Correct Answer: C
Rationale: The correct answer is C: Call adult protective services because you suspect elder mistreatment. In this scenario, the patient's presentation raises concerns for elder abuse, as evidenced by the presence of a stage 3 pressure ulcer, old bruising, and the patient's unkempt appearance. By involving adult protective services, the nurse can initiate an investigation to ensure the safety and well-being of the patient. This step is crucial in addressing potential abuse and protecting the vulnerable adult. Summary: A: Calling social services for nursing home placement is premature without investigating the suspected abuse. B: Asking the son to step out may not address the potential abuse and could hinder the assessment. D: While assessing cognitive status is important, addressing suspected elder mistreatment takes precedence in this situation.
Question 4 of 5
The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: The correct answer is C. Assess the respiratory status and pulse oximeter reading. This is the first intervention the nurse should implement because it provides crucial information about the client's current oxygenation status and respiratory function. By assessing these parameters, the nurse can quickly identify any immediate issues that may require intervention, such as respiratory distress or hypoxemia. Confirming ventilator settings (A) and verifying ventilator alarms (B) are important tasks but assessing the client's respiratory status takes priority as it directly impacts the client's oxygenation and ventilation. Monitoring arterial blood gas results (D) is important for evaluating the effectiveness of ventilation but is not the first step in managing a client on a ventilator.
Question 5 of 5
When the V/Q lung scan result returns with a mismatch ratio that is greater than 1, which condition should be suspected?
Correct Answer: C
Rationale: The correct answer is C: Pulmonary embolus. A V/Q lung scan is used to evaluate the ventilation-perfusion ratio in the lungs. A mismatch ratio greater than 1 indicates a significant ventilation-perfusion mismatch, which is commonly seen in pulmonary embolism where there is a blockage in the pulmonary artery. This leads to decreased perfusion in areas of the lung, causing the mismatch. Therefore, when the mismatch ratio is greater than 1, pulmonary embolus should be suspected. Choices A, B, and D do not directly correlate with a mismatch ratio on a V/Q lung scan, making them incorrect in this context.