ATI RN
Client Safety Event ATI Quizlet Questions
Question 1 of 5
The nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing:
Correct Answer: A
Rationale: Step 1: Delirium is characterized by acute onset confusion, agitation, hallucinations, and disorientation, which align with the patient's symptoms. Step 2: The patient's sudden change in mental status suggests an acute condition rather than a chronic one like dementia. Step 3: The inability to recognize her daughter and mistaking her for a stranger are typical features of delirium. Step 4: The daughter's report of sudden confusion and hallucinations points towards delirium rather than worsening dementia or new-onset dementia. Step 5: Therefore, based on the acute onset of symptoms and the patient's confusion and hallucinations, the nurse correctly suspects delirium. Summary: - B: Depression does not typically present with acute confusion, hallucinations, and disorientation. - C: New-onset dementia would not manifest suddenly with confusion and hallucinations. - D: Worsening dementia would show a gradual decline rather than a sudden onset of symptoms.
Question 2 of 5
The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first?
Correct Answer: B
Rationale: The correct answer is B: Ventilate with a manual resuscitation bag. This intervention is crucial as it addresses the immediate need for oxygenation and ventilation in a client with ARDS. By manually ventilating the client, the nurse can ensure an adequate supply of oxygen while the ventilator issue is being addressed. Option A is incorrect because waiting for the respiratory therapist may delay necessary intervention. Option C, requesting ABGs, is not the priority as the client's oxygenation needs must be addressed first. Option D, auscultating lung sounds, is important but not as urgent as ensuring proper ventilation. Prioritizing ventilation with a manual resuscitation bag is crucial to prevent hypoxia and respiratory failure in a client with ARDS.
Question 3 of 5
The nurse is caring for a patient diagnosed with ARDS who is showing signs of respiratory fatigue. Which of the following findings would indicate respiratory fatigue?
Correct Answer: B
Rationale: The correct answer is B because a change in respiratory rate from rapid to slow indicates respiratory fatigue. Initially, the body compensates for ARDS by increasing respiratory rate; however, as fatigue sets in, the rate slows down. Option A is incorrect as increased use of accessory muscles is a sign of respiratory distress, not fatigue. Option C is incorrect as orthopnea with shallow breathing suggests difficulty breathing while lying down, not necessarily fatigue. Option D is incorrect as cyanosis indicates poor oxygenation, not specifically fatigue.
Question 4 of 5
To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with
Correct Answer: A
Rationale: Correct Answer: A. Arterial blood gas (ABG) analysis Rationale: 1. ABG analysis provides precise measurements of oxygenation (PaO2) and ventilation (PaCO2). 2. ABG is the gold standard for assessing respiratory function. 3. It allows for the identification of acid-base disturbances. 4. ABG provides immediate feedback for timely interventions. Summary of Other Choices: B. Hemodynamic monitoring: Primarily assesses cardiovascular function, not specific to respiratory status. C. Chest x-rays: Helpful for evaluating lung pathology but does not provide direct information on oxygenation and ventilation. D. Pulse oximetry: Measures oxygen saturation only, not ventilation status or CO2 levels.
Question 5 of 5
Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring?
Correct Answer: A
Rationale: The correct answer is A: The patient has subcutaneous emphysema. Subcutaneous emphysema is a possible complication of mechanical ventilation with high levels of PEEP in ARDS. This occurs when air escapes from the alveoli and becomes trapped under the skin. It is a sign of barotrauma, indicating that the PEEP levels may be too high for the patient. Subcutaneous emphysema can lead to serious complications such as pneumothorax, so it is crucial for the nurse to recognize and address it promptly. Explanation of other choices: B: Sinus bradycardia is not directly related to ventilator therapy complications. C: Low PaO2 and SaO2 levels are expected in ARDS and do not specifically indicate a complication of ventilator therapy. D: Bronchial breath sounds can be present in ARDS but do not specifically indicate a complication of ventilator therapy.