ATI RN
Client Safety Basic Concept Template Questions
Question 1 of 5
When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about the risk for poor oxygenation because of
Correct Answer: C
Rationale: The correct answer is C because in pulmonary fibrosis, there is thickening of the alveoli which leads to decreased transfer of oxygen into the blood. This happens because the thickened alveolar walls make it harder for oxygen to pass from the air sacs into the bloodstream. This results in poor oxygenation of the blood. Option A is incorrect because too-rapid movement of blood flow through the pulmonary blood vessels does not directly affect oxygenation in pulmonary fibrosis. Option B is incorrect because incomplete filling of the alveoli with air due to reduced respiratory ability may impact oxygenation, but this is not the primary mechanism in pulmonary fibrosis. Option D is incorrect because a mismatch between lung ventilation and blood flow through the blood vessels is not the main issue in pulmonary fibrosis; it is more relevant in conditions like pulmonary embolism.
Question 2 of 5
In ARDS, initially the patient experiences respiratory alkalosis due to the increased CO2 being expelled out from the increased respiratory rate. The nurse knows that which of the following factors contributes to the later signs of respiratory acidosis?
Correct Answer: B
Rationale: The correct answer is B: Hyaline membranes form which does not allow CO2 escape, increasing the CO2 concentration in the blood. Rationale: 1. In ARDS, damage to the alveoli leads to the formation of hyaline membranes. 2. These membranes impede gas exchange, particularly the elimination of CO2. 3. As CO2 accumulates in the blood, it leads to respiratory acidosis. 4. The other choices are incorrect as they do not directly relate to the impaired elimination of CO2, which is the key factor in causing respiratory acidosis in ARDS.
Question 3 of 5
You, the nurse, have been monitoring the client with subcutaneous emphysema around the shoulder and lower neck. You notice that the area has expanded and is traveling up the neck. Based on your knowledge, what should the nurse anticipate doing in the near future?
Correct Answer: D
Rationale: The correct answer is D: Assisting with tracheostomy insertion. Subcutaneous emphysema traveling up the neck suggests a potential airway compromise due to air leaking into surrounding tissues. Tracheostomy insertion may be necessary to establish a secure airway and prevent further complications. This intervention takes precedence over other options as it addresses the immediate threat to the client's airway and breathing. Options A, B, and C do not directly address the escalating subcutaneous emphysema and potential airway obstruction, making them less appropriate in this urgent situation.
Question 4 of 5
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct: 1. Incident reports are used to document unexpected or adverse events. 2. A missing personal item, such as dentures, can impact a client's well-being. 3. It is essential to investigate and address the situation promptly. 4. Completing an incident report ensures proper documentation and follow-up. Summary of why other choices are incorrect: A. Identifying broken equipment is important but does not directly impact a client's safety or well-being. B. Staff attendance issues should be reported through appropriate channels but may not require an incident report. D. Disagreements with supervisors are common workplace issues but do not warrant an incident report unless they involve patient safety.
Question 5 of 5
A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?
Correct Answer: B
Rationale: The correct answer is B because a platelet count of 60,000/mm3 is significantly low (normal range: 150,000-450,000/mm3) and can indicate a risk of bleeding during surgery. The nurse needs to follow up to ensure appropriate interventions are taken. A: A BUN of 15 mg/dL is within the normal range (7-20 mg/dL). C: A WBC count of 6,000/mm3 is within the normal range (4,500-11,000/mm3). D: A hemoglobin level of 14 g/dL is within the normal range for males (13.5-17.5 g/dL) and females (12.0-15.5 g/dL).