ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
Subnormal core body temperature
Correct Answer: B
Rationale: The correct answer is B: Hypothermia. Subnormal core body temperature indicates the body temperature is below normal range, which is characteristic of hypothermia. Hyperthermia refers to elevated body temperature, making choice A incorrect. Choices C and D are likely not provided as they do not directly relate to the concept of body temperature.
Question 2 of 5
A nurse is planning client care for herself and an assistive personnel (AP). Which task should the nurse plan to perform?
Correct Answer: C
Rationale: The correct answer is C: Assessing a client's sacrum for edema. The nurse should plan to perform this task as it requires clinical judgment and assessment skills, which are within the scope of nursing practice. The nurse can identify early signs of skin breakdown and provide appropriate interventions. Explanation of other choices: A: Administration of an enema - This task can be safely delegated to an assistive personnel as long as the client's condition is stable. B: Application of antiembolic stockings - This task does not require clinical judgment and can be delegated to an assistive personnel. D: Assisting a client to cough and deep breathe - This task can be delegated to an assistive personnel as long as the client's condition is stable.
Question 3 of 5
After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with
Correct Answer: D
Rationale: The correct answer is D, inserting a pulmonary artery catheter. This is the most appropriate action to differentiate between ARDS and pulmonary edema caused by left ventricular failure. The pulmonary artery catheter can provide valuable information such as pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac output. In ARDS, the pulmonary artery pressure and pulmonary capillary wedge pressure are typically low, whereas in pulmonary edema due to left ventricular failure, these pressures are elevated. Positioning the patient for a chest radiograph (A) would provide anatomical information but not differentiate between ARDS and pulmonary edema. Drawing blood for arterial blood gases (B) can provide information on oxygenation but may not be sufficient to differentiate between the two conditions. Obtaining a ventilation-perfusion scan (C) is not typically used to differentiate between ARDS and pulmonary edema.
Question 4 of 5
What is the leading cause of injury-related deaths in adults 65 and older?
Correct Answer: A
Rationale: The correct answer is A: Falls. Older adults are at higher risk of falls due to factors like decreased balance and mobility. Falls are the leading cause of injury-related deaths in this age group. Violence (B) is less common, alcoholism (C) is a health issue but not the leading cause of injury-related deaths, and MVAs (D) are more common in younger age groups.
Question 5 of 5
Oral temperature, best
Correct Answer: B
Rationale: The correct answer is B (Under tongue) for taking oral temperature. This method is widely used and recommended for its accuracy and convenience. Placing the thermometer under the tongue ensures direct contact with saliva, providing a more accurate reflection of core body temperature. Taking temperature in the gums (A) may not provide as reliable results due to variations in saliva production and positioning. No information is given for choices C and D.