ATI RN
Client Health and Safety Specifications Questions
Question 1 of 5
The nurse is completing an admission assessment with an 80-year-old man who experienced a hip fracture following a fall. He is alert, lives alone, and has very poor hygiene. He reports a 20-pound weight loss in the last 6 months following his wife's death, as well as estrangement from his only child. He admits to falls before this most recent fall. What should the nurse suspect?
Correct Answer: D
Rationale: The correct answer is A: Dementia. Given the patient's age, history of falls, poor hygiene, weight loss, social isolation, and cognitive impairment, dementia is the most likely suspicion. The patient's cognitive decline may have contributed to the falls, poor self-care, and social isolation. Weight loss and cognitive decline following a significant life event (wife's death) are common in dementia. Delirium (C) is typically acute and reversible, not chronic like dementia. Elder abuse (B) may be a concern but is not the most likely cause based on the information provided. Alcohol abuse (D) is not supported by the patient's history and presentation.
Question 2 of 5
The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory arrest when the patient displays which behavior?
Correct Answer: D
Rationale: The correct answer is D because a change in respiratory rate from rapid to slow indicates impending respiratory failure. Initially, a rapid respiratory rate is a compensatory mechanism to maintain oxygenation. However, a shift to slow breathing suggests fatigue and impending respiratory arrest. A: Incorrect. Inability to breathe unless sitting upright is indicative of orthopnea, not necessarily respiratory fatigue leading to respiratory arrest. B: Incorrect. Using abdominal muscles during expiration is a normal breathing pattern and may not necessarily indicate impending respiratory arrest. C: Incorrect. An increased inspiratory-expiratory ratio may indicate respiratory distress but not specifically respiratory fatigue leading to respiratory arrest.
Question 3 of 5
The nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency department has
Correct Answer: A
Rationale: The correct answer is A: chest trauma and multiple rib fractures. This condition can lead to impaired ventilation and hypoventilation, resulting in retention of carbon dioxide (hypercapnia). The other choices do not directly lead to hypercapnia. B: carbon monoxide poisoning affects oxygen transport, not carbon dioxide levels. C: left-sided ventricular failure causes hypoxia, not hypercapnia. D: tachypnea in ARDS may lead to hypocapnia, not hypercapnia. Therefore, chest trauma with rib fractures is the most likely scenario to cause hypercapnia.
Question 4 of 5
When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse?
Correct Answer: A
Rationale: The correct answer is A: The patient is somnolent. This indicates potential respiratory fatigue, requiring immediate intervention. Somnolence suggests worsening respiratory function, leading to further CO2 retention. SpO2 at 90% (choice B) is concerning but not as urgent as hypercapnia. Weakness (choice C) is a common symptom but not as critical as somnolence. Blood pressure of 162/94 (choice D) is high but not directly related to respiratory failure. Prioritize addressing the somnolence to prevent further deterioration.
Question 5 of 5
A 26-year-old patient is admitted to the hospital in severe respiratory distress. His oxygen saturations are 80% despite supplemental oxygen provided by facemask. The physician decides to intubate the patient to help with his breathing oxygenation. Which medication would the nurse most likely administer when assisting with intubation?
Correct Answer: A
Rationale: The correct answer is A: Midazolam (Versed). Midazolam is a benzodiazepine used for sedation and anxiolysis before intubation to ensure patient comfort and cooperation. It has rapid onset and short duration, making it ideal for this situation. Zolpidem (B) is a sedative-hypnotic used for insomnia, not suitable for intubation. Phentermine (C) is a weight-loss medication and has no role in intubation. Modafinil (D) is a wakefulness-promoting agent and is not used for intubation. In summary, Midazolam is the correct choice for its sedative properties in facilitating intubation, while the other options are not appropriate for this scenario.