ATI RN
Essentials of Nursing Client Safety Questions
Question 1 of 5
Dr. Monira reports that she got a needle stick while working from patient infected with hepatitis C(HCV). She was asked to perform HCV antibody test. What is the likely reason for this testing?
Correct Answer: B
Rationale: Testing confirms exposure and potential infection.
Question 2 of 5
A nurse responds to an IV pump alarm related to increased pressure. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct action is to check for kinking of the catheter first. This is because increased pressure in the IV pump alarm could indicate a blockage, likely caused by a kink in the catheter. By checking for kinking, the nurse can quickly identify and resolve the issue, restoring proper flow and preventing complications. Flushing the catheter with a thrombolytic enzyme (B) is unnecessary and could be harmful without knowing the exact cause. Getting a new infusion pump (C) is premature as the issue may lie with the catheter itself. Removing the IV catheter (D) should be a last resort after troubleshooting other potential causes.
Question 3 of 5
During an admission assessment, a nurse asks a client diagnosed with schizophrenia, "Have you ever felt that certain objects or persons have control over your behavior?" The nurse is assessing for which type of thought disruption?
Correct Answer: B
Rationale: The correct answer is B: Delusions of influence. This type of delusion involves the belief that external forces are controlling one's thoughts or actions. In this scenario, the nurse is specifically asking about the client's perception of objects or persons having control over their behavior, which aligns with delusions of influence. A: Delusions of persecution involve the belief that one is being targeted or harmed by others. C: Delusions of reference involve the belief that neutral events or objects have personal significance. D: Delusions of grandeur involve an exaggerated sense of importance or power. In summary, the nurse's question is assessing for delusions of influence because it directly pertains to the client's belief about external control over their behavior, distinguishing it from the other types of delusions mentioned.
Question 4 of 5
A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?
Correct Answer: A
Rationale: The correct answer is A: sore throat. Clozapine can cause agranulocytosis, a potentially life-threatening side effect characterized by a low white blood cell count. A sore throat may indicate infection due to decreased white blood cells, necessitating immediate intervention to prevent serious complications. Incorrect options: B: Fever - While fever can indicate infection, a sore throat is a more specific symptom of agranulocytosis related to clozapine. C: Malaise - Generalized discomfort is nonspecific and does not directly correlate with the serious side effect of agranulocytosis. D: Akathisia and hypersalivation - These side effects are common with antipsychotic medications, including clozapine, but they are not indicative of the life-threatening condition of agranulocytosis.
Question 5 of 5
The nurse has been assigned the same patients for the past 3 days. Two of the patients demand a great deal of attention, so the nurse feels anxious and angry about being given this assignment again. How can the nurse cope with this patient care assignment?
Correct Answer: C
Rationale: The correct answer is C. Prioritizing the patients' needs and identifying a specific time period for care for each patient is the most effective way for the nurse to cope with the patient care assignment. By organizing and scheduling care, the nurse can ensure that all patients receive appropriate attention without feeling overwhelmed. Option A is incorrect because sharing complaints with the nurse manager may not directly address the issue of coping with the assignment. Option B is incorrect as it does not provide a structured approach to managing the workload. Option D is incorrect as it does not address the underlying issue of time management and prioritization.