ATI RN
Client Safety Questions
Question 1 of 5
The student nurse diligently assesses her patient with a chest tube. She notices that the suction control chamber of the chest tube is not bubbling. What is the first thing this student should do?
Correct Answer: C
Rationale: The student nurse should first check the level of suction on the wall because the absence of bubbling in the suction control chamber indicates a potential issue with the suction level. Checking the suction setting ensures that the chest tube is functioning properly. Documenting this as normal (choice A) is incorrect because it could lead to overlooking a problem. Encouraging the patient to cough and deep breathe (choice B) is not relevant to addressing the issue with the chest tube. Clamping the chest tube and calling for help (choice D) is dangerous and could compromise the patient's condition. Therefore, checking the suction level on the wall (choice C) is the appropriate initial action to take.
Question 2 of 5
A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
Correct Answer: D
Rationale: The correct answer is D. The nurse should have the AP check to see if the elbow restraint is in place for the infant postoperative from cleft palate surgery first. This task is a safety priority to ensure the infant's postoperative care and prevent any complications related to the surgical correction. It requires immediate attention to prevent injury or complications. Choices A, B, and C are important tasks but not as urgent as ensuring the safety and well-being of a postoperative infant. Collecting a stool sample, engaging a toddler in play, and washing the hair of an adolescent can be done after ensuring the immediate safety and well-being of the postoperative infant.
Question 3 of 5
A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directive. Which of the following statements by the client indicates a need for clarification?
Correct Answer: C
Rationale: The correct answer is C because the statement "I have to choose a family member as my health proxy" is incorrect. The client does not have to choose a family member as their health care proxy; they can choose any trusted individual to act as their proxy. This indicates a need for clarification as the client may be under the misconception that the proxy must be a family member. Statement A is not the correct answer because the client can indeed change their designated health care proxy at any time. Statement B is not the correct answer because end-of-life choices are typically made by the proxy only if the client is unable to make decisions themselves. Statement D is not the correct answer because the health care proxy does go into effect as soon as it is designated, not only when the client is incapable of making decisions.
Question 4 of 5
A nurse is preparing discharge instructions for a client receiving oxygen at home. What should the nurse include?
Correct Answer: A
Rationale: The correct answer is A: Do not adjust the oxygen flow rate. This is crucial for maintaining the prescribed oxygen therapy and preventing potential harm to the client. Adjusting the flow rate without medical guidance can lead to inadequate oxygenation or oxygen toxicity. Incorrect Choices: B: Checking oxygen equipment weekly is important for safety but not directly related to the client's immediate oxygen use. C: Storing oxygen tanks horizontally is incorrect as they should be stored upright to prevent leaks. D: Using wool blankets to reduce static is not recommended as they can generate static electricity, posing a risk of fire near oxygen.
Question 5 of 5
A client who fell and broke his hip while being assisted to the bathroom by a nurse states he plans to sue the nurse. The nurse should know that, in a legal proceeding, the standard that will be used to determine if the nurse was negligent is which of the following?
Correct Answer: B
Rationale: The correct answer is B: Another staff nurse provides testimony about how a reasonable, prudent nurse would have handled the situation. In a legal proceeding to determine if the nurse was negligent, the standard used is typically that of what a reasonable and prudent nurse would have done in the same situation. This standard is known as the "standard of care." It is important because it assesses the nurse's actions based on what is considered acceptable and appropriate within the nursing profession. Testimony from another staff nurse who can provide insight into how a reasonable and prudent nurse would have acted is crucial in establishing whether the nurse in question met this standard. Choice A is incorrect because testimony from an expert nurse about how the situation should have been handled differently may not necessarily reflect the standard of care for a reasonable and prudent nurse. Choice C is incorrect because the client's attorney stating that the injury could have been prevented does not establish the standard of care for a nurse in the situation. Choice D is incorrect because the client's provider