ATI RN
Client Safety in Nursing Questions
Question 1 of 5
What is a key strategy in preventing ventilator-associated pneumonia (VAP) in patients with ARDS?
Correct Answer: B
Rationale: The correct answer is B: Frequent oral care with chlorhexidine. This is key in preventing VAP by reducing bacterial colonization in the oral cavity, decreasing the risk of aspiration. Nasopharyngeal suctioning (A) can irritate the airway and increase the risk of infection. Administering prophylactic antibiotics (C) can lead to antibiotic resistance. Increasing tidal volumes (D) can worsen lung injury in ARDS patients. Overall, maintaining good oral hygiene is crucial in preventing VAP in patients with ARDS.
Question 2 of 5
A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patient's family members are anxious about the patient's condition and are continuously present at the hospital. In addressing the family's concerns, it is important for the nurse to
Correct Answer: A
Rationale: The correct answer is A because in the fibrotic phase of ARDS, the chance of survival is poor. Supporting the family and helping them understand this realistic expectation is crucial for their emotional preparation. Choice B is incorrect because maintaining mechanical ventilation at home post-discharge is not feasible. Choice C is incorrect as transferring the patient to a long-term care facility may not be appropriate at this stage. Choice D is incorrect because stating that the disease process has started to resolve is inaccurate in the fibrotic phase.
Question 3 of 5
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action?
Correct Answer: A
Rationale: The correct answer is A: Perform endotracheal intubation and initiate mechanical ventilation. In ARDS, nonrebreather mask may not provide adequate oxygenation due to severe lung damage. Intubation and mechanical ventilation can provide higher levels of oxygen and positive end-expiratory pressure to improve oxygenation. CPAP (choice B) may not be sufficient for severe cases of ARDS. Administering furosemide (Lasix) (choice C) is not appropriate for poor oxygenation in ARDS. Calling a code for respiratory arrest (choice D) is premature and not indicated unless the patient's condition deteriorates to that extent.
Question 4 of 5
A nurse is providing care for a surgeon on a medical-surgical unit. A nurse from another unit asks the nurse about the surgeon's medical diagnosis. The nurse responds that he is unable to provide the information requested. The nurse is displaying which of the following ethical principles?
Correct Answer: D
Rationale: The correct answer is D. Nonmaleficence. The nurse is displaying the ethical principle of nonmaleficence by refusing to disclose the surgeon's medical diagnosis without permission. Nonmaleficence means to do no harm, and sharing sensitive medical information without consent could potentially harm the surgeon's privacy and confidentiality. A. Utility focuses on maximizing benefits and minimizing harm for the greater good, which is not directly related to the nurse's action in this scenario. B. Paternalism involves making decisions for a patient's best interest without their consent, which is not applicable here as the nurse is respecting the surgeon's autonomy. C. Justice refers to fairness and equal treatment, which is not the primary ethical principle being demonstrated in this situation.
Question 5 of 5
A nurse in an acute care setting is serving on a committee whose charge is to use the auditing process to client care. Which of the following aspects of client care is measured by a process audit?
Correct Answer: C
Rationale: Step 1: Process audits focus on evaluating the procedures and processes involved in providing care. Step 2: Quality of nursing care provided is directly related to the processes and procedures followed by nursing staff. Step 3: By conducting a process audit, the committee can assess if the established procedures are being followed to ensure quality care. Step 4: Availability of resources and nursing staff ratios are important but are more related to structural or outcome audits. Step 5: Length of facility stay for a cohort of clients is an outcome measure and not directly related to the process of providing care. Summary: The correct answer is C because process audits assess the quality of care provided through evaluating the procedures followed, while the other choices are not directly related to the processes of care provision.