ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?
Correct Answer: D
Rationale: The correct answer is D because inserting a nasogastric tube requires a higher level of skill and knowledge that an LPN possesses. LPNs are trained to perform more complex clinical tasks such as inserting nasogastric tubes. Postmortem care (A) is generally not within the scope of practice for LPNs. Measuring I&O (B) and obtaining weight (C) are tasks that can be safely delegated to assistive personnel as they are routine and do not require the clinical judgment and skill level of an LPN.
Question 2 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.
Question 3 of 5
Vesicle on the leg
Correct Answer: B
Rationale: The correct answer is B because a vesicle is a small fluid-filled blister on the skin. Vesicles are commonly caused by friction, burns, or insect bites, resulting in fluid accumulation beneath the skin. Pus is typically associated with larger, infected lesions such as pustules, not vesicles. Choice C and D are likely incorrect as they do not provide relevant information or support for the appearance of a vesicle on the leg.
Question 4 of 5
A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?
Correct Answer: D
Rationale: The correct answer is D: Respite care. Respite care provides temporary relief for the primary caregiver, allowing them time to attend to their own needs and errands. This support can help prevent caregiver burnout and ensure the client receives consistent care. Hospice care (A) is not appropriate as the client is not in end-of-life care. Restorative care (B) focuses on rehabilitation, which is not the primary concern in this case. Mental health care (C) may be beneficial but does not directly address the caregiver's need for time off.
Question 5 of 5
When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first?
Correct Answer: D
Rationale: The correct action is to assess vital signs and pulse oximetry first. This is essential to determine if the patient's agitation and confusion are due to hypoxia, a common complication in chronic lung disease. Monitoring the patient every 10-15 minutes (choice A) may delay identifying and addressing the underlying issue. Notifying the healthcare provider immediately (choice B) is important but assessing the patient's condition takes precedence. Attempting to calm and reassure the patient (choice C) is helpful but not the priority when the patient's safety is at risk. Assessing vital signs and pulse oximetry (choice D) is crucial for immediate intervention if hypoxia is detected.