ATI RN
Essentials Of Nursing Client Safety Questions
Question 1 of 5
When auscultating a client's abdomen, how long should the nurse listen before concluding the bowel sounds are absent?
Correct Answer: B
Rationale: The correct answer is B: 5 minutes. The nurse should listen for 5 minutes before concluding bowel sounds are absent because it allows sufficient time to accurately assess bowel activity. Listening for only 1 minute (A) may not provide a comprehensive understanding. Listening for 10 minutes (C) or 15 minutes (D) is excessive and unnecessary, as bowel sounds are usually heard within the first few minutes. Therefore, 5 minutes strikes a balance between thorough assessment and efficient use of time.
Question 2 of 5
A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.)
Correct Answer: A
Rationale: Step 1: The patient retiring from a management role after 20 years indicates a significant change in his daily routine and identity. Step 2: Being a dedicated employee for 42 years, work has likely been a major part of his life. The loss of his work role can lead to a sense of loss, purposelessness, and identity crisis. Step 3: Social isolation (choice B) may be a concern, but the question emphasizes the patient's work role and dedication, making choice A more critical. Step 4: The wife's employment status (choice C) and household tasks division (choice D) are not directly related to the patient's major concerns. Summary: The major concern for the patient is the loss of his work role, which can impact his sense of purpose and identity. Social isolation, the wife's employment, and household tasks division are not as significant in this context.
Question 3 of 5
The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement?
Correct Answer: A
Rationale: The correct answer is A because demonstrating the correct technique for giving a bed bath ensures proper care for the client with ARDS. This includes maintaining proper positioning to prevent respiratory distress. Encouraging the UAP to put the bed in the lowest position (B) is incorrect as it may not be necessary and could potentially worsen the client's condition. Instructing the UAP to get another person to help (C) is unnecessary and may delay care. Providing praise for performing the bath safely (D) is inappropriate as it does not address the importance of proper technique in caring for a client with ARDS.
Question 4 of 5
When teaching the patient about what was happening when experiencing an intrapulmonary shunt, which explanation is accurate?
Correct Answer: C
Rationale: The correct answer is C. In an intrapulmonary shunt, blood flows through the capillaries in the lungs without participating in gas exchange. This leads to poorly oxygenated blood mixing with well-oxygenated blood, reducing overall oxygenation levels. Choice A is incorrect because it describes a ventilation-perfusion mismatch, not an intrapulmonary shunt. Choice B is incorrect as it describes an intracardiac shunt, not an intrapulmonary shunt. Choice D is incorrect as it refers to conditions like pulmonary fibrosis, not intrapulmonary shunts.
Question 5 of 5
A patient with ARDS is placed on low tidal volume ventilation. What is the primary benefit of this strategy?
Correct Answer: B
Rationale: The correct answer is B: To minimize the risk of barotrauma and volutrauma. Low tidal volume ventilation in ARDS reduces the risk of lung injury by decreasing the pressure and volume delivered to the lungs, thus lowering the chances of barotrauma (lung injury from high pressure) and volutrauma (lung injury from excessive volume). This strategy helps protect the fragile alveoli, prevents further damage, and improves outcomes. Choice A is incorrect because low tidal volume ventilation does not directly prevent fluid accumulation in the alveoli. Choice C is incorrect because it focuses on carbon dioxide elimination, which is not the primary goal of low tidal volume ventilation in ARDS. Choice D is incorrect because although improving perfusion in dependent lung areas is important, it is not the primary benefit of low tidal volume ventilation in ARDS.