ATI RN
Client Safety Basic Concept Template Questions
Question 1 of 5
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube care?
Correct Answer: D
Rationale: The correct answer is D: Ensure that the ET tube is secure. This is important to prevent accidental extubation and maintain proper airway support. Securing the ET tube also prevents movement that can lead to tissue damage. Option A is incorrect as the ET tube may need adjustment. Option B is unnecessary unless there are specific concerns. Option C is important but ensuring the tube is secure takes precedence.
Question 2 of 5
When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about the risk for poor oxygenation because of
Correct Answer: C
Rationale: The correct answer is C because in pulmonary fibrosis, there is thickening of the alveoli which leads to decreased transfer of oxygen into the blood. This happens because the thickened alveolar walls make it harder for oxygen to pass from the air sacs into the bloodstream. This results in poor oxygenation of the blood. Option A is incorrect because too-rapid movement of blood flow through the pulmonary blood vessels does not directly affect oxygenation in pulmonary fibrosis. Option B is incorrect because incomplete filling of the alveoli with air due to reduced respiratory ability may impact oxygenation, but this is not the primary mechanism in pulmonary fibrosis. Option D is incorrect because a mismatch between lung ventilation and blood flow through the blood vessels is not the main issue in pulmonary fibrosis; it is more relevant in conditions like pulmonary embolism.
Question 3 of 5
The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider?
Correct Answer: D
Rationale: The correct answer is D. A drop in SpO2 to 90% despite an increase in O2 flow rate indicates worsening respiratory status, which is a critical concern in a patient with aspiration pneumonia. This information is crucial to communicate to the healthcare provider for prompt intervention. Explanation: 1. SpO2 is a direct measure of oxygen saturation in the blood, indicating how well the patient is oxygenating. 2. A drop in SpO2 below 90% is concerning as it indicates hypoxemia and potential respiratory distress. 3. Despite increasing the O2 flow rate, the drop in SpO2 suggests that the patient's condition is deteriorating. 4. Prompt intervention is needed to prevent further respiratory compromise and potential respiratory failure. Summary: A: Productive cough with blood-tinged sputum may indicate lung infection, but it's not as critical as hypoxemia. B: Crackles throughout lung bases are common in pneumonia but don't directly indicate worsening respiratory status
Question 4 of 5
In ARDS, initially the patient experiences respiratory alkalosis due to the increased CO2 being expelled out from the increased respiratory rate. The nurse knows that which of the following factors contributes to the later signs of respiratory acidosis?
Correct Answer: B
Rationale: The correct answer is B: Hyaline membranes form which does not allow CO2 escape, increasing the CO2 concentration in the blood. Rationale: 1. In ARDS, damage to the alveoli leads to the formation of hyaline membranes. 2. These membranes impede gas exchange, particularly the elimination of CO2. 3. As CO2 accumulates in the blood, it leads to respiratory acidosis. 4. The other choices are incorrect as they do not directly relate to the impaired elimination of CO2, which is the key factor in causing respiratory acidosis in ARDS.
Question 5 of 5
You, the nurse, have been monitoring the client with subcutaneous emphysema around the shoulder and lower neck. You notice that the area has expanded and is traveling up the neck. Based on your knowledge, what should the nurse anticipate doing in the near future?
Correct Answer: D
Rationale: The correct answer is D: Assisting with tracheostomy insertion. Subcutaneous emphysema traveling up the neck suggests a potential airway compromise due to air leaking into surrounding tissues. Tracheostomy insertion may be necessary to establish a secure airway and prevent further complications. This intervention takes precedence over other options as it addresses the immediate threat to the client's airway and breathing. Options A, B, and C do not directly address the escalating subcutaneous emphysema and potential airway obstruction, making them less appropriate in this urgent situation.