ATI RN
Client Safety Questions
Question 1 of 5
Upon skin inspection of an older adult, the coccyx wound is noted to be intact, reddened, and non-blanchable. What is the best way to document the nurse's assessment finding?
Correct Answer: A
Rationale: The correct way to document the nurse's assessment finding of an intact, reddened, and non-blanchable coccyx wound in an older adult is as a stage I pressure injury. A stage I pressure injury is characterized by intact skin with non-blanchable redness. In this case, the skin is intact, showing the initial signs of tissue damage due to pressure. Stages II, III, and IV pressure injuries involve more severe damage to the skin and underlying tissues. Stage II involves partial-thickness skin loss, stage III involves full-thickness skin loss, and stage IV involves full-thickness skin loss with extensive tissue necrosis. Since the coccyx wound is only showing redness without any loss of skin integrity, it aligns with a stage I pressure injury. Choices B, C, and D are incorrect as they describe more advanced stages of pressure injuries with skin breakdown, which is not present in this case.
Question 2 of 5
A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.)
Correct Answer: A
Rationale: The correct answer is A: Impaired vision. The patient's bifocal glasses indicate vision impairment, which is a significant fall risk factor as it affects depth perception and balance. This is evident as the patient experiences weakness in his legs when climbing stairs, which could be due to the visual impairment affecting his ability to judge distance and steps. The other choices are incorrect: Residence design (B) is not a factor since they live in a one-level ranch home; Blood pressure (C) is stable and not a fall risk factor in this case; Leg weakness (D) is a symptom of the patient's diabetes and could contribute to falls but is not the primary risk factor in this scenario.
Question 3 of 5
Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS?
Correct Answer: B
Rationale: The correct answer is B: A synthetic surfactant. In ARDS, the alveoli become stiff and collapse, leading to impaired gas exchange. Synthetic surfactant helps reduce surface tension in the alveoli, improving lung compliance and gas exchange. Aminoglycoside antibiotics (A) are not typically used in ARDS. Potassium cation (C) is not a medication used to treat ARDS. Nonsteroidal anti-inflammatory drugs (D) do not address the underlying pathophysiology of ARDS.
Question 4 of 5
A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, how should the nurse position the patient?
Correct Answer: A
Rationale: The correct answer is A: On the left side. Placing the patient on the left side helps to improve ventilation-perfusion (V/Q) matching by allowing the unaffected left lung to expand fully. This position can help redistribute blood flow to the functioning lung, improving oxygenation. Choice B: On the right side would not be appropriate as it would further compromise the affected right lung. Choice C: In a reclining chair bed may not be ideal for promoting optimal lung expansion and V/Q matching. Choice D: Supine with the head of the bed elevated may not be as effective in improving V/Q matching compared to positioning on the left side.
Question 5 of 5
A patient is diagnosed with a large pulmonary embolism. When explaining to the patient what has happened to cause respiratory failure, which information will the nurse include?
Correct Answer: D
Rationale: The correct answer is D because in a large pulmonary embolism, a blood clot obstructs blood flow in the pulmonary arteries, leading to decreased blood flow to parts of the lungs despite adequate breathing. This mismatch between ventilation and perfusion causes respiratory failure. A is incorrect because thick membranes between air sacs and lung circulation do not play a significant role in pulmonary embolism. B is incorrect as it describes bronchial blockage, not pulmonary embolism. C is incorrect because it describes a mismatch in ventilation and perfusion but does not specifically relate to decreased blood flow due to a pulmonary embolism.