ATI RN
Client Safety in Nursing Questions
Question 1 of 5
The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A: Check the tubing for any kinks. This is the first intervention to implement because increased peak airway pressure can be caused by a kink in the tubing, leading to ineffective ventilation. Checking for kinks ensures proper airflow to the client's lungs. Suctioning for secretions (B) may be necessary but should come after ruling out tubing issues. Assessing the lip line of the ET tube (C) is important for proper placement but does not address the immediate high peak airway pressure concern. Sedating the client with a muscle relaxant (D) should not be the first intervention as it does not address the underlying cause of the high peak airway pressure.
Question 2 of 5
A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate?
Correct Answer: B
Rationale: The correct answer is B: Endotracheal intubation and positive pressure ventilation. In hypercapnic respiratory failure, the patient's respiratory rate is low, indicating inadequate ventilation. The SpO2 of 89% and increasing lethargy suggest severe hypoxemia and impending respiratory failure. Endotracheal intubation allows for mechanical ventilation to improve oxygenation and ventilation. Positive pressure ventilation can help improve gas exchange and prevent further deterioration. A: Administration of 100% oxygen by non-rebreather mask would not address the underlying issue of inadequate ventilation in hypercapnic respiratory failure. C: Insertion of a mini-tracheostomy with frequent suctioning is not the initial intervention for managing hypercapnic respiratory failure. D: Initiation of bilevel positive pressure ventilation (BiPAP) may not be sufficient for this patient with impending respiratory failure; endotracheal intubation provides better control over ventilation and oxygenation.
Question 3 of 5
A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patient's family members are anxious about the patient's condition and are continuously present at the hospital. In addressing the family's concerns, it is important for the nurse to
Correct Answer: A
Rationale: The correct answer is A because in the fibrotic phase of ARDS, the chance of survival is poor. Supporting the family and helping them understand this realistic expectation is crucial for their emotional preparation. Choice B is incorrect because maintaining mechanical ventilation at home post-discharge is not feasible. Choice C is incorrect as transferring the patient to a long-term care facility may not be appropriate at this stage. Choice D is incorrect because stating that the disease process has started to resolve is inaccurate in the fibrotic phase.
Question 4 of 5
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action?
Correct Answer: A
Rationale: The correct answer is A: Perform endotracheal intubation and initiate mechanical ventilation. In ARDS, nonrebreather mask may not provide adequate oxygenation due to severe lung damage. Intubation and mechanical ventilation can provide higher levels of oxygen and positive end-expiratory pressure to improve oxygenation. CPAP (choice B) may not be sufficient for severe cases of ARDS. Administering furosemide (Lasix) (choice C) is not appropriate for poor oxygenation in ARDS. Calling a code for respiratory arrest (choice D) is premature and not indicated unless the patient's condition deteriorates to that extent.
Question 5 of 5
A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?
Correct Answer: D
Rationale: The correct answer is D. Nonmaleficence. The nurse is displaying the ethical principle of nonmaleficence by refusing to disclose the surgeon's medical diagnosis without permission. Nonmaleficence means to do no harm, and sharing sensitive medical information without consent could potentially harm the surgeon's privacy and confidentiality. A. Utility focuses on maximizing benefits and minimizing harm for the greater good, which is not directly related to the nurse's action in this scenario. B. Paternalism involves making decisions for a patient's best interest without their consent, which is not applicable here as the nurse is respecting the surgeon's autonomy. C. Justice refers to fairness and equal treatment, which is not the primary ethical principle being demonstrated in this situation.