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
Sputum collection, wrong
Correct Answer: B
Rationale: The correct answer is B: Clear and light sample. This is because sputum should ideally be clear and light in color, indicating a lower presence of mucus and other contaminants. A cloudy, thick sample (choice A) may indicate an infection or presence of pus. Choices C and D are likely left blank as they are irrelevant or incorrect responses. In summary, a clear and light sputum sample is preferred for accurate testing and diagnosis.
Question 3 of 5
A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?
Correct Answer: A
Rationale: The correct answer is A: Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. This task should be completed first because monitoring blood glucose levels is essential for clients with diabetes who are on short-acting insulin to prevent hypoglycemia. Timely monitoring allows the nurse to assess the client's current glucose level and adjust the insulin dose if needed before the client eats breakfast. Choice B is incorrect because applying a condom catheter to an incontinent client is important but not as time-sensitive as blood glucose monitoring for a client on short-acting insulin. Choice C is incorrect because while feeding a client with bilateral casts is important for nutrition and comfort, it is not as time-sensitive as monitoring blood glucose levels for a client on short-acting insulin. Choice D is incorrect because delivering a clean voided urine specimen to the laboratory is important for diagnostic purposes, but it is not as time-sensitive as monitoring blood glucose levels for a client on short-acting
Question 4 of 5
Two adult siblings are caring for their ill mother, who requires 24-hour care: she needs assistance with feeding, bathing, and toileting. One of the siblings takes time to exercise after work. The other sibling goes directly to the mother's home before and after work each day. The nurse recognizes that people may react differently to the same stressors depending on various factors. What are some of these factors? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: Amount of perceived stress. This is because individuals may react differently to stressors based on how they perceive the level of stress they are experiencing. Factors such as previous experiences, personality, and support systems can influence how stress is perceived. Hair color (B) and skin type (D) are not relevant factors in how individuals react to stress. Individual coping skills (C) are important, but they are more about how individuals manage stress rather than how they initially perceive it.
Question 5 of 5
A paranoid client presents with bizarre behaviors, neologisms, and thought insertion. Which nursing action should be prioritized to maintain this client's safety?
Correct Answer: B
Rationale: The correct answer is B: Note escalating behaviors and intervene immediately. This is the priority as the client is exhibiting signs of acute psychosis, indicating a risk to their safety. By noting escalating behaviors and intervening immediately, the nurse can prevent potential harm to the client or others. Assessing for medication noncompliance (Choice A) is important but not the priority in this acute situation. Interpreting attempts at communication (Choice C) can be done after ensuring immediate safety. Assessing triggers for bizarre behaviors (Choice D) is not as urgent as intervening to prevent harm.