ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
Skin care, correct
Correct Answer: B
Rationale: The correct answer is B: Leave the pimple. Pinching a pimple can lead to inflammation, scarring, and further spread of bacteria. Leaving the pimple allows it to heal naturally, reducing the risk of complications. It is important to practice gentle skincare to promote healthy skin and avoid causing damage or irritation. Other choices are incorrect as they involve actions that can harm the skin and worsen the condition.
Question 2 of 5
A client is diagnosed with schizophrenia. A physician orders haloperidol (Haldol) 50 mg bid, benztropine (Cogentin) 1 mg prn, and zolpidem (Ambien) 10 mg HS. Which client behavior would warrant the nurse to administer benztropine?
Correct Answer: C
Rationale: The correct answer is C: Restlessness and muscle rigidity. Benztropine is an anticholinergic medication commonly used to treat extrapyramidal symptoms such as restlessness and muscle rigidity, which can occur as side effects of antipsychotic medications like haloperidol. Tactile hallucinations (choice A) would not be a direct indication for benztropine. Tardive dyskinesia (choice B) is a late side effect of antipsychotic medications and is not an acute symptom requiring benztropine. Reports of hearing disturbing voices (choice D) are indicative of auditory hallucinations, which would not be treated with benztropine.
Question 3 of 5
First defense against infection
Correct Answer: B
Rationale: The correct answer is B: Intact skin. Intact skin acts as the first defense against infection by forming a physical barrier that prevents pathogens from entering the body. It is composed of multiple layers, including the epidermis and dermis, which provide protection against microbes. Skin also produces antimicrobial substances and has immune cells that can defend against pathogens. A: Skin is not specific enough, as damaged skin may not provide effective protection. C and D are incomplete answers and do not accurately describe the primary role of intact skin in defending against infections.
Question 4 of 5
A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?
Correct Answer: A
Rationale: The correct answer is A: Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. This task should be completed first because monitoring blood glucose levels is essential for clients with diabetes who are on short-acting insulin to prevent hypoglycemia. Timely monitoring allows the nurse to assess the client's current glucose level and adjust the insulin dose if needed before the client eats breakfast. Choice B is incorrect because applying a condom catheter to an incontinent client is important but not as time-sensitive as blood glucose monitoring for a client on short-acting insulin. Choice C is incorrect because while feeding a client with bilateral casts is important for nutrition and comfort, it is not as time-sensitive as monitoring blood glucose levels for a client on short-acting insulin. Choice D is incorrect because delivering a clean voided urine specimen to the laboratory is important for diagnostic purposes, but it is not as time-sensitive as monitoring blood glucose levels for a client on short-acting
Question 5 of 5
After an explosion at a factory one of the employees approaches the nurse and says 'I am an unlicensed assistive personnel (UAP) at the local hospital.' Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers?
Correct Answer: C
Rationale: The correct answer is C: Palpate pulses. This task should be assigned first because assessing the pulses can provide crucial information about the injured workers' circulation and perfusion status. By palpating pulses, the unlicensed assistive personnel can quickly identify any signs of compromised circulation or potential life-threatening conditions. This immediate assessment is essential for prioritizing care and determining the urgency of further interventions. Other choices are incorrect because: A: Getting temperatures can be important but not as immediately critical as assessing pulses for circulatory status. B: Taking blood pressure may provide valuable information, but assessing pulses gives a more direct indication of perfusion. D: Checking alertness is important, but assessing pulses should be the priority for immediate life-saving interventions.