ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 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 2 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 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
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.
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 indicates potential airway compromise. Tracheostomy insertion may be necessary to secure the airway and prevent further complications. Surgery (choice A) may not address the immediate need for securing the airway. Encouraging the client to use the Incentive Spirometer (IS) (choice B) or palpating the area (choice C) would not address the urgency of the situation or provide a definitive solution to the airway compromise.