ATI RN
Client Safety in Nursing Questions
Question 1 of 5
The nurse cares for a middle-aged client who is on furosemide for congestive heart failure (CHF). The nurse assesses the client for possible symptoms of:
Correct Answer: A
Rationale: The correct answer is A: hypokalemia. Furosemide is a loop diuretic that can cause potassium loss through increased urine output. Hypokalemia can result in cardiac dysrhythmias, muscle weakness, and fatigue. The nurse should monitor potassium levels regularly and educate the client on consuming potassium-rich foods. B: Hyperkalemia is incorrect because furosemide usually causes potassium loss, not retention. C: Hypocalcemia is incorrect because furosemide does not directly affect calcium levels. D: Hypernatremia is incorrect because furosemide primarily affects potassium and fluid balance, not sodium levels.
Question 2 of 5
The nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started noticing a glare in the lights at home. Her vision is blurred; and she is unable to play cards with her friends, read, or do her needlework. The nurse suspects that the woman may have:
Correct Answer: C
Rationale: The correct answer is C: Cataract(s). The symptoms described by the patient, such as glare in lights, blurred vision, and difficulty with near vision tasks, are indicative of cataracts, which is a common age-related condition where the lens of the eye becomes cloudy. Presbyopia (A) is a normal age-related condition causing difficulty focusing on near objects. Presbycusis (B) is age-related hearing loss, not related to the symptoms described. Depression (D) may present with some visual disturbances, but the patient's symptoms are more consistent with cataracts.
Question 3 of 5
In most ethical dilemmas in health care, the solution to the dilemma requires negotiation among members of the health care team. Why is the nurse's point of view valuable?
Correct Answer: C
Rationale: The correct answer is C because nurses develop a unique relationship with the patient, which allows them to provide valuable insights into the patient's preferences, values, and needs. This relationship enables nurses to advocate effectively for the patient's best interests and ensure that the patient's voice is heard in ethical discussions. Choice A is incorrect because understanding the principle of autonomy is not unique to nurses and does not necessarily make their point of view more valuable in ethical dilemmas. Choice B is also incorrect as the scope of practice does not inherently make the nurse's point of view more valuable in ethical discussions; it simply defines the tasks they are allowed to perform. Choice D is incorrect because while the nurse's code of ethics may recommend their presence at ethical discussions, it does not inherently make their point of view more valuable than other healthcare team members.
Question 4 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 5 of 5
What is a key strategy in preventing ventilator-associated pneumonia (VAP) in patients with ARDS?
Correct Answer: B
Rationale: The correct answer is B: Frequent oral care with chlorhexidine. This is key in preventing VAP by reducing bacterial colonization in the oral cavity, decreasing the risk of aspiration. Nasopharyngeal suctioning (A) can irritate the airway and increase the risk of infection. Administering prophylactic antibiotics (C) can lead to antibiotic resistance. Increasing tidal volumes (D) can worsen lung injury in ARDS patients. Overall, maintaining good oral hygiene is crucial in preventing VAP in patients with ARDS.