ATI RN
Client Safety ATI Chapter 13 Questions
Question 1 of 5
Old patient taking a bath
Correct Answer: B
Rationale: In the context of client safety, the correct answer is B) With doors closed when an old patient is taking a bath. This option ensures both privacy and safety for the patient. Keeping the doors closed allows for privacy while ensuring that the patient is safe and secure within the bathing area. Option A) With doors locked may pose a safety risk in case of an emergency. If the doors are locked, it may impede quick access to the patient in case they need assistance or if an emergency situation arises. In an educational setting, it is crucial to emphasize the balance between providing privacy and ensuring safety for clients, especially vulnerable populations such as older patients. Teaching students the importance of maintaining a safe environment during client care activities like bathing helps instill best practices that prioritize both dignity and safety for the individuals they will care for in their future careers. Remember, always prioritize patient safety while respecting their privacy and dignity.
Question 2 of 5
A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?
Correct Answer: D
Rationale: Upper extremity swelling could indicate infiltration, and the PICC will need to be removed. The initial dressing over the PICC site should be changed within 24 hours. This does not require immediate attention, but the swelling does. The dwell time for PICCs can be months or even years. Securement devices are being used more often now to secure the catheter in place and prevent complications such as phlebitis and infiltration. The IV should have one, but this does not take priority over the client whose arm is swollen.
Question 3 of 5
Parents ask a nurse how they should reply when their child, diagnosed with paranoid schizophrenia, tells them that voices command him to harm others. Which is the appropriate nursing reply?
Correct Answer: C
Rationale: The most appropriate response by the nurse is to instruct the parents to focus on the feelings generated by the hallucinations and present reality. The parents should maintain an attitude of acceptance to encourage communication but should not reinforce the hallucinations by exploring details of content.
Question 4 of 5
After taking chlorpromazine (Thorazine) for 1 month, a client presents to an emergency department (ED) with severe muscle rigidity, tachycardia, and a temperature of 105°F (40.5°C). The nurse expects the physician to recognize which condition and implement which treatment?
Correct Answer: A
Rationale: The nurse should expect that an ED physician would diagnose the client with neuroleptic malignant syndrome and treat the client by discontinuing chlorpromazine (Thorazine) and administering dantrolene (Dantrium). Neuroleptic malignant syndrome is a potentially fatal condition characterized by muscle rigidity, fever, altered consciousness, and autonomic instability.
Question 5 of 5
As the emergency room (ER) nurse responds to a client who suddenly goes into cardiac arrest, which substance in the body will be secreted in large amounts?
Correct Answer: C
Rationale: In this scenario, the correct answer is C) Epinephrine. When a client goes into cardiac arrest, the body initiates the stress response known as the fight-or-flight response. Epinephrine, also known as adrenaline, is a hormone released by the adrenal glands in response to stress. It plays a crucial role in increasing heart rate, constricting blood vessels, and dilating air passages to increase oxygen delivery to the body's tissues during emergencies like cardiac arrest. Option A) Endorphin is incorrect because endorphins are the body's natural painkillers and are not typically secreted in large amounts during a sudden cardiac arrest. Option B) Endothelin is incorrect as it is a peptide that constricts blood vessels, but it is not the primary hormone secreted in response to cardiac arrest. Option D) Erythropoietin is incorrect as it is a hormone primarily involved in the production of red blood cells and the regulation of blood oxygen levels, not in the immediate response to cardiac arrest. In an educational context, understanding the body's response to stress and emergencies like cardiac arrest is crucial for healthcare providers, especially nurses working in emergency settings. Knowing the role of hormones like epinephrine can help nurses anticipate and respond effectively to critical situations, ultimately improving patient outcomes.