ATI RN
Client Safety Questions
Question 1 of 5
When assessing visual acuity of the older adult, which visual finding is associated with aging?
Correct Answer: B
Rationale: The correct answer is B: Presbyopia. Presbyopia is a common age-related condition where the eye's lens loses flexibility, leading to difficulty focusing on close objects. Myopia (choice A), nearsightedness, is not specifically associated with aging. Strabismus (choice C), misalignment of the eyes, typically develops in childhood. Astigmatism (choice D), an irregular curvature of the eye's cornea or lens, can affect people of all ages, not just older adults. Presbyopia is the most relevant choice for visual changes associated with aging due to the natural aging process affecting the eye's ability to focus on close objects.
Question 2 of 5
A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first?
Correct Answer: D
Rationale: The correct answer is D. The increase in the patient's temperature and dark urine could indicate a urinary tract infection (UTI), a common issue in older adults with indwelling catheters. The patient's confusion could be a sign of systemic infection. The RN should recommend a urine culture to confirm UTI and initiate appropriate treatment. A is incorrect because confusion in an older adult should not be dismissed without investigating the underlying cause. B is incorrect as increasing fluid intake may dilute the urine but does not address the potential infection. C is incorrect as the assessment findings are not normal and should not be ignored.
Question 3 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 4 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 5 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.