ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
Sleep comfort, wrong.
Correct Answer: A
Rationale: The correct answer is A: Make patient tired before sleeping. This is because physical and mental exhaustion can improve sleep quality. By engaging in activities that make the patient tired, such as exercise or mental stimulation, they are more likely to fall asleep faster and have a deeper, more restful sleep. Providing milk, as in choice B, may be relaxing for some individuals, but it is not a guaranteed method to improve sleep comfort. Choice C and D are left blank, as they do not offer any relevant information related to improving sleep comfort.
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
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.
Question 4 of 5
the environment is warm
Correct Answer: A
Rationale: The correct answer is A because in a warm environment, the body needs to cool itself to maintain a stable internal temperature. This process is called thermoregulation. Sweating and vasodilation are mechanisms the body uses to release heat and cool down. Choice B is incorrect as the body does not need to warm itself in a warm environment. Choices C and D are incomplete and do not offer a logical explanation related to the situation given.
Question 5 of 5
Maintenance of fluid balance in the patient with ARDS involves
Correct Answer: C
Rationale: Step-by-step rationale for choice C being correct: 1. ARDS patients have increased capillary permeability leading to fluid leakage into the lungs. 2. Mild fluid restriction helps prevent fluid overload and pulmonary edema. 3. Diuretics help manage any excess fluid accumulation. 4. Hydration using colloids (choice A) can exacerbate fluid overload. 5. Surfactant (choice B) is used in neonatal respiratory distress syndrome, not ARDS. 6. Keeping hemoglobin level >12 g/dL (choice D) is unrelated to fluid balance in ARDS.