ATI RN
Client Safety Nursing Questions
Question 1 of 5
The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Obtain oxygen saturation using pulse oximetry. In a patient with sepsis, it is crucial to assess oxygen saturation to evaluate respiratory status and tissue perfusion. The patient's vital signs indicate signs of respiratory distress (elevated temperature, increased respirations) and potential hypoperfusion (low blood pressure). Oxygen saturation will provide critical information on the patient's oxygenation status. A: Notifying the healthcare provider may be necessary but addressing the immediate respiratory concern is the priority. C: Documenting and monitoring are important, but immediate intervention is needed due to the patient's critical condition. D: Administering acetaminophen is not appropriate at this time as the priority is to assess and address respiratory distress and potential hypoperfusion.
Question 2 of 5
A charge nurse has access to the facility's electronic client records. It is appropriate for the charge nurse to share her personal password with whom?
Correct Answer: B
Rationale: The correct answer is B: No one. Sharing personal passwords violates confidentiality and security protocols. The charge nurse is responsible for safeguarding client information and should not share her password with anyone, including the nurse manager, nursing student, or unit clerk. Sharing passwords can lead to unauthorized access to sensitive data, compromising client privacy and violating HIPAA regulations. It is essential to maintain individual accountability for accessing electronic records to ensure data integrity and protect client confidentiality.
Question 3 of 5
Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge?
Correct Answer: A
Rationale: The correct answer is A. The young adult client with Crohn's disease preoperative for an ileostomy can be recommended for discharge as the surgery is planned and stable. - Choice B: The adolescent with a spontaneous pneumothorax may need further monitoring and care due to the severity of the condition. - Choice C: The middle adult postoperative from an open laminectomy requires close monitoring for complications and pain management. - Choice D: The older adult with diabetic ketoacidosis and a pH of 7.32 still needs treatment and monitoring for stabilization.
Question 4 of 5
A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications?
Correct Answer: A
Rationale: The correct answer is A. Euphoria. Opioid medications can cause euphoria due to their effects on the brain's reward system. This can lead to misuse and addiction. Rhinorrhea (B), hallucinations (C), and dilated pupils (D) are not typical adverse effects of opioid medications. Rhinorrhea is more commonly associated with allergies or colds, hallucinations are more commonly associated with certain psychiatric disorders or drug intoxication, and dilated pupils are more commonly associated with stimulant use.
Question 5 of 5
A nurse is planning a community diabetes mellitus management program. What goal should the nurse include?
Correct Answer: B
Rationale: The correct answer is B because reducing the incidence of foot amputations is a crucial goal in managing diabetes mellitus. This goal focuses on preventing severe complications and improving quality of life for clients. Choice A is too specific and may not address the overall goal of preventing complications. Choice C does not relate directly to client outcomes. Choice D, while important for education, does not specifically address the health outcome of reducing foot amputations. Thus, B is the most appropriate goal for a community diabetes management program.