ATI RN
Client Safety Nursing Skill Template Questions
Question 1 of 5
During a night shift in the ICU, the cardiac monitor sound is suddenly changed, so that the physician is alerted and hurried up to see the case. What is the cause of this rapid response?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 of 5
A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure?
Correct Answer: D
Rationale: The correct answer is D, placing a washcloth between the skin and tourniquet. This helps protect the client's skin by providing a barrier to prevent direct pressure and friction from the tourniquet. It reduces the risk of skin damage and potential irritation. A: Lowering the extremity below the level of the heart is not necessary for protecting the skin during catheter insertion. B: Applying warm compresses may not necessarily protect the skin and can potentially increase the risk of skin damage. C: Tapping the skin lightly and avoiding slapping is unrelated to protecting the skin during the procedure.
Question 3 of 5
A client diagnosed with schizophrenia states, "Can't you hear him? It's the devil. He's telling me I'm going to hell." Which is the most appropriate nursing reply?
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the client's experience while also providing reassurance and reality orientation. By stating that the voices sound scary and attributing them to the illness, the nurse validates the client's feelings and offers a non-judgmental response. This approach helps build trust and rapport with the client, while also providing education about the nature of their symptoms. Choice A is incorrect because it focuses solely on medication adherence without addressing the client's concerns. Choice B is incorrect because it dismisses the client's experience and offers a blanket reassurance without addressing the delusional content. Choice D is incorrect because it oversimplifies the situation and does not provide therapeutic communication or support for the client's distress.
Question 4 of 5
If clozapine (Clozaril) therapy is being considered, the nurse should evaluate which laboratory test to establish a baseline for comparison in order to recognize a potentially life-threatening side effect?
Correct Answer: A
Rationale: The correct answer is A: White blood cell count. Clozapine can cause agranulocytosis, a potentially life-threatening side effect characterized by severe neutropenia. Evaluating the white blood cell count before starting clozapine therapy establishes a baseline for comparison. Regular monitoring of WBC count is essential to promptly recognize and manage this serious adverse reaction. Summary: - Choice A (White blood cell count) is correct because it helps in monitoring for agranulocytosis. - Choices B, C, and D are incorrect as they do not directly relate to the specific side effect of clozapine therapy.
Question 5 of 5
After having an argument with a spouse, which defense mechanism is the patient exhibiting when becoming verbally abusive toward the nurse?
Correct Answer: D
Rationale: The correct answer is D: Displacement. Displacement is a defense mechanism where one transfers their emotions or impulses from the original source to a less threatening target. In this scenario, the patient is redirecting their anger from their spouse to the nurse, a less threatening target. This behavior allows the patient to avoid dealing directly with the conflict. A: Denial involves refusing to accept reality. B: Projection is attributing one's own unacceptable feelings or thoughts to others. C: Sublimation is channeling unacceptable impulses into socially acceptable actions.