ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 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.
Question 2 of 5
Maintenance of fluid balance in the patient with ARDS involves
Correct Answer: C
Rationale: Step-by-step rationale for choice C being correct: 1. ARDS patients have increased capillary permeability leading to fluid leakage into the lungs. 2. Mild fluid restriction helps prevent fluid overload and pulmonary edema. 3. Diuretics help manage any excess fluid accumulation. 4. Hydration using colloids (choice A) can exacerbate fluid overload. 5. Surfactant (choice B) is used in neonatal respiratory distress syndrome, not ARDS. 6. Keeping hemoglobin level >12 g/dL (choice D) is unrelated to fluid balance 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 indicates potential airway compromise. Tracheostomy insertion may be necessary to secure the airway and prevent further complications. Surgery (choice A) may not address the immediate need for securing the airway. Encouraging the client to use the Incentive Spirometer (IS) (choice B) or palpating the area (choice C) would not address the urgency of the situation or provide a definitive solution to the airway compromise.
Question 4 of 5
A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?
Correct Answer: D
Rationale: The correct answer is D, Nonmaleficence. This principle emphasizes the obligation to do no harm to the patient. By discontinuing the experimental medication upon evidence of rapidly advancing kidney failure, the nurse is prioritizing the patient's well-being and preventing further harm. This decision aligns with the ethical duty to avoid causing harm to the patient. Now, let's analyze why the other choices are incorrect: A. Veracity: Veracity refers to truth-telling. Discontinuing the medication is not specifically related to truth-telling but rather to preventing harm. B. Autonomy: Autonomy relates to respecting the patient's right to make decisions about their care. Discontinuing the medication may be a decision made by the healthcare team based on patient safety, not necessarily the patient's autonomous choice. C. Fidelity: Fidelity involves being faithful and maintaining trust in the patient-nurse relationship. Discontinuing the medication can be seen as upholding fidelity by acting in the patient's
Question 5 of 5
A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse?
Correct Answer: C
Rationale: The correct answer is C. Transferring a client to the discharge location would be the lowest priority for the nurse during a disaster simulation. Priority should be given to immediate actions that ensure the safety and well-being of all clients. Here's a step-by-step rationale: 1. Preventing cross-contamination (choice A) is crucial to prevent the spread of the toxic substance. 2. Performing concise client assessment (choice B) is essential to identify and prioritize care for clients based on their needs. 3. Maintaining a client tracking system (choice D) is vital for ensuring accountability and continuity of care. 4. Transferring a client to the discharge location (choice C) can be delayed as it is not immediately life-threatening or crucial for the initial response.