ATI RN
Client Safety Quizlet Questions
Question 1 of 5
The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A: Assess the client's level of consciousness. In ARDS, hypoxemia can lead to altered mental status. Assessing the client's level of consciousness is crucial for detecting any neurological changes and ensuring timely intervention. Monitoring urine output (B) is important for assessing renal function but is not a priority in ARDS. Turning the client every two hours (C) is a standard nursing intervention for preventing pressure ulcers but is not directly related to managing ARDS. Maintaining intravenous fluids as ordered (D) is important, but assessing the client's level of consciousness takes precedence in the care of a client with ARDS.
Question 2 of 5
A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a
Correct Answer: B
Rationale: The correct answer is B because a PaO2 of 45 mm Hg indicates hypoxemia, a common feature of acute respiratory failure. In acute respiratory failure, the patient's lungs are unable to provide enough oxygen to meet the body's demands, leading to low oxygen levels in the blood. Shallow breathing (choice A) is a sign of respiratory distress but not specific to acute respiratory failure. A PaCO2 of 34 mm Hg (choice C) is within the normal range and would not indicate acute respiratory failure. A respiratory rate of 32/min (choice D) may indicate respiratory distress but alone is not sufficient to confirm acute respiratory failure.
Question 3 of 5
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct?
Correct Answer: D
Rationale: Rationale: Correct Answer (D): PEEP prevents the lung air sacs from collapsing during exhalation. PEEP helps maintain lung recruitment by keeping the air sacs open at the end of expiration, preventing collapse and improving oxygenation. This is crucial in patients with ARDS to prevent atelectrauma and improve gas exchange. Incorrect Choices: A: Incorrect. PEEP does not prevent fibrosis of the lung. Its primary purpose is to maintain lung recruitment. B: Incorrect. PEEP does not push more air into the lungs during inhalation but helps keep the lungs open during exhalation. C: Incorrect. PEEP does not directly control the oxygen percentage delivered by the ventilator; its main role is to maintain lung volume.
Question 4 of 5
The high-pressure alarm on a patient's ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?
Correct Answer: C
Rationale: The correct answer is C: Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. This is the best course of action because the patient is in distress with low oxygen saturation and struggling to sit up, indicating a critical situation. Manually ventilating the patient ensures adequate oxygenation and ventilation while addressing the high-pressure alarm issue promptly. Assessing the possible reasons for the alarm is crucial to identify and address the underlying problem causing the high pressure. Choice A is incorrect because inserting an oral airway is not the priority in this situation and may delay addressing the patient's respiratory distress. Choice B is incorrect as reassuring the patient does not address the underlying issue of the high-pressure alarm and the patient's deteriorating condition. Choice D is incorrect as increasing the fraction of inspired oxygen without assessing the reason for the high-pressure alarm may not resolve the issue and could potentially worsen the patient's condition.
Question 5 of 5
A nurse is caring for a client who is dying of metastatic breast cancer. She has a prescription for an opioid pain medication PRN. The nurse is concerned that administering a dose of pain medication might hasten the client's death. Which of the following ethical principles should the nurse use to support the decision not to administer the medication?
Correct Answer: B
Rationale: The correct answer is B. Nonmaleficence. Nonmaleficence is the ethical principle of "do no harm." In this scenario, the nurse should prioritize relieving the client's pain and suffering while ensuring that the medication does not cause harm or hasten the client's death. Administering the pain medication in this context aligns with the principle of nonmaleficence. Choice A (Utilitarianism) focuses on the greatest good for the greatest number and may prioritize the client's comfort over prolonging life, which is not the main concern in this scenario. Choice C (Fidelity) relates to being faithful to commitments and agreements and does not directly address the issue of administering pain medication. Choice D (Veracity) pertains to truthfulness and honesty in communication, which is not directly relevant to the decision of administering the pain medication in this situation.