ATI RN
Client Safety Basic Concept Template Questions
Question 1 of 5
The nurse is working with an older adult after an acute hospitalization. The goal is to help this person be more in touch with time, place, and person. Which intervention will likely be most effective?
Correct Answer: C
Rationale: The correct answer is C: Reality orientation. This intervention involves helping the older adult understand and be more aware of their time, place, and person. It helps them stay oriented to their surroundings and maintain a sense of reality. This can be achieved through methods like displaying clocks, calendars, and familiar objects, providing consistent communication about time and place, and encouraging engagement in daily routines. Reminiscence (A) focuses on recalling past memories, Validation therapy (B) validates the emotions and feelings of the individual rather than emphasizing reality, and Body image interventions (D) are unrelated to the goal of helping the person be more in touch with time, place, and person.
Question 2 of 5
A patient has a PaO2 of 50 mm Hg and a PaCO2 of 42 mm Hg because of an intrapulmonary shunt. Which therapy is the patient most likely to respond best to?
Correct Answer: A
Rationale: The correct answer is A: Positive pressure ventilation. Positive pressure ventilation helps improve oxygenation by increasing the mean airway pressure, which helps recruit collapsed alveoli and improve ventilation-perfusion matching in the presence of an intrapulmonary shunt. This therapy can effectively increase the PaO2 levels in this patient. Choice B: Oxygen administration at a FIO2 of 100% may not be sufficient to overcome the intrapulmonary shunt and improve oxygenation significantly. Choice C: Administration of O2 per nasal cannula at 1 to 3 L/min may not provide enough oxygen to overcome the shunting effect and improve oxygenation adequately. Choice D: Clearance of airway secretions with coughing and suctioning may be beneficial for airway clearance but is not directly related to correcting the underlying oxygenation issue caused by the intrapulmonary shunt.
Question 3 of 5
When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about the risk for poor oxygenation because of
Correct Answer: C
Rationale: The correct answer is C because in pulmonary fibrosis, there is thickening of the alveoli which leads to decreased transfer of oxygen into the blood. This happens because the thickened alveolar walls make it harder for oxygen to pass from the air sacs into the bloodstream. This results in poor oxygenation of the blood. Option A is incorrect because too-rapid movement of blood flow through the pulmonary blood vessels does not directly affect oxygenation in pulmonary fibrosis. Option B is incorrect because incomplete filling of the alveoli with air due to reduced respiratory ability may impact oxygenation, but this is not the primary mechanism in pulmonary fibrosis. Option D is incorrect because a mismatch between lung ventilation and blood flow through the blood vessels is not the main issue in pulmonary fibrosis; it is more relevant in conditions like pulmonary embolism.
Question 4 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 5 of 5
In ARDS, initially the patient experiences respiratory alkalosis due to the increased CO2 being expelled out from the increased respiratory rate. The nurse knows that which of the following factors contributes to the later signs of respiratory acidosis?
Correct Answer: B
Rationale: The correct answer is B: Hyaline membranes form which does not allow CO2 escape, increasing the CO2 concentration in the blood. Rationale: 1. In ARDS, damage to the alveoli leads to the formation of hyaline membranes. 2. These membranes impede gas exchange, particularly the elimination of CO2. 3. As CO2 accumulates in the blood, it leads to respiratory acidosis. 4. The other choices are incorrect as they do not directly relate to the impaired elimination of CO2, which is the key factor in causing respiratory acidosis in ARDS.