ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
What is the leading cause of injury-related deaths in adults 65 and older?
Correct Answer: A
Rationale: The correct answer is A: Falls. Older adults are at higher risk of falls due to factors like decreased balance and mobility. Falls are the leading cause of injury-related deaths in this age group. Violence (B) is less common, alcoholism (C) is a health issue but not the leading cause of injury-related deaths, and MVAs (D) are more common in younger age groups.
Question 2 of 5
When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain?
Correct Answer: A
Rationale: Correct Answer: A: Fidelity Rationale: 1. Fidelity refers to the nurse's duty to uphold the patient's best interests and maintain trust. 2. By continually reviewing the pain management plan with the patient, the nurse demonstrates fidelity by ensuring the patient's priority of being free of pain is met. 3. Monitoring the patient's response to pain aligns with fidelity as it shows the nurse's commitment to the patient's well-being and trust. 4. Fidelity promotes a therapeutic nurse-patient relationship based on honesty and loyalty. Summary of Incorrect Choices: B: Beneficence - Focuses on doing good for the patient, but does not specifically address the nurse's duty to monitor and uphold the patient's priority of pain management. C: Nonmaleficence - Focuses on avoiding harm, but does not specifically address the nurse's role in monitoring and ensuring the patient's priority of pain management. D: Respect for autonomy - Focuses on respecting the patient's right to make
Question 3 of 5
The health-care provider ordered STAT arterial blood gases for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A: Continue to monitor the client without taking any action. The ABG results indicate a pH within the normal range (7.35-7.45), PaO2 is slightly lower than normal but still adequate for tissue oxygenation, PaCO2 is within the normal range (35-45), and HCO3 is normal (22-26). These values indicate that the client's acid-base balance is within normal limits, and no immediate intervention is needed. Encouraging deep breaths and coughing (B) may be beneficial for some respiratory conditions but is not indicated here. Administering sodium bicarbonate IVP (C) is unnecessary as the client's pH and HCO3 levels are normal. Notifying the respiratory therapist (D) is not warranted since the ABG results do not indicate any acute respiratory distress. Monitoring the client (A) is the appropriate action as the ABG results are stable.
Question 4 of 5
A patient with ARDS is being mechanically ventilated. The physician has ordered prone positioning. What is the primary reason for this intervention?
Correct Answer: D
Rationale: The correct answer is D. Prone positioning helps recruit collapsed alveoli by redistributing ventilation to dependent lung regions, improving oxygenation in ARDS. It enhances lung homogeneity and reduces stress on the dorsal lung regions. Choices A, B, and C are incorrect because prone positioning primarily aims to optimize oxygenation by improving lung ventilation and perfusion, rather than solely reducing diaphragm workload, enhancing perfusion to anterior lung segments, or mobilizing secretions.
Question 5 of 5
When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first?
Correct Answer: D
Rationale: The correct action is to assess vital signs and pulse oximetry first. This is essential to determine if the patient's agitation and confusion are due to hypoxia, a common complication in chronic lung disease. Monitoring the patient every 10-15 minutes (choice A) may delay identifying and addressing the underlying issue. Notifying the healthcare provider immediately (choice B) is important but assessing the patient's condition takes precedence. Attempting to calm and reassure the patient (choice C) is helpful but not the priority when the patient's safety is at risk. Assessing vital signs and pulse oximetry (choice D) is crucial for immediate intervention if hypoxia is detected.