ATI RN
Client Safety Basic Concept Template Questions
Question 1 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 2 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.
Question 3 of 5
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Incident reports are used to document unexpected or adverse events. 2. A missing personal item, such as dentures, can impact a client's well-being. 3. It is essential to investigate and address the situation promptly. 4. Completing an incident report ensures proper documentation and follow-up. Summary of why other choices are incorrect: A. Identifying broken equipment is important but does not directly impact a client's safety or well-being. B. Staff attendance issues should be reported through appropriate channels but may not require an incident report. D. Disagreements with supervisors are common workplace issues but do not warrant an incident report unless they involve patient safety.
Question 4 of 5
A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?
Correct Answer: B
Rationale: The correct answer is B because a platelet count of 60,000/mm3 is significantly low (normal range: 150,000-450,000/mm3) and can indicate a risk of bleeding during surgery. The nurse needs to follow up to ensure appropriate interventions are taken. A: A BUN of 15 mg/dL is within the normal range (7-20 mg/dL). C: A WBC count of 6,000/mm3 is within the normal range (4,500-11,000/mm3). D: A hemoglobin level of 14 g/dL is within the normal range for males (13.5-17.5 g/dL) and females (12.0-15.5 g/dL).
Question 5 of 5
While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first?
Correct Answer: C
Rationale: The correct answer is C: Wash the site of injury with soap and water. This is the first action the nurse should take to minimize the risk of infection. Washing the site immediately helps remove any potential pathogens. It is crucial to act promptly in order to reduce the risk of transmission. Incorrect choices: A: Completing an incident report can be important but should not be the first step in this situation. B: Requesting the risk manager to obtain consent for HIV testing from the client is not the immediate priority. D: Consenting to postexposure treatment with antiretroviral medications is important, but washing the site of injury should come first to prevent infection.