ATI RN
Client Safety Questions
Question 1 of 5
When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patient's family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate?
Correct Answer: C
Rationale: Step-by-step rationale for the correct answer (C): 1. Urinary tract infection (UTI) triggers a systemic inflammatory response. 2. Systemic inflammation can lead to a condition called sepsis. 3. Sepsis can cause widespread inflammation in the body, including the lungs. 4. This generalized inflammation can result in damage to the lung tissue, leading to acute respiratory distress syndrome (ARDS). Summary of why other choices are incorrect: A: Incorrect because UTI does not directly spread to the lungs through circulation. B: Incorrect because toxins produced by UTI typically affect the urinary system, not the lungs. D: Incorrect because fever associated with infection does not directly cause scar tissue formation in the lungs.
Question 2 of 5
The student nurse diligently assesses her patient with a chest tube. She notices that the suction control chamber of the chest tube is not bubbling. What is the first thing this student should do?
Correct Answer: C
Rationale: The student nurse should first check the level of suction on the wall because the absence of bubbling in the suction control chamber indicates a potential issue with the suction level. Checking the suction setting ensures that the chest tube is functioning properly. Documenting this as normal (choice A) is incorrect because it could lead to overlooking a problem. Encouraging the patient to cough and deep breathe (choice B) is not relevant to addressing the issue with the chest tube. Clamping the chest tube and calling for help (choice D) is dangerous and could compromise the patient's condition. Therefore, checking the suction level on the wall (choice C) is the appropriate initial action to take.
Question 3 of 5
A staff nurse has applied for a promotion. The hiring manager insinuates that if there was a sexual relationship between the two of them, the nurse's promotion request would get increased consideration. Which of the following actions should the staff nurse take first?
Correct Answer: A
Rationale: The correct answer is A. The staff nurse should first directly address the inappropriate behavior with the hiring manager. By clearly stating that the conduct causes discomfort and requesting it to stop immediately, the nurse sets clear boundaries and asserts their rights. This action establishes a record of the nurse's response to the misconduct and gives the hiring manager the opportunity to rectify the situation. It also empowers the nurse to advocate for themselves in a professional manner. Summary: - B: Reporting to the nurse manager can be done after addressing the hiring manager directly. - C: Creating a written document can be important but should follow direct communication. - D: Seeking help from a friend can provide support but should not replace direct confrontation with the hiring manager.
Question 4 of 5
A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
Correct Answer: D
Rationale: The correct answer is D. The nurse should have the AP check to see if the elbow restraint is in place for the infant postoperative from cleft palate surgery first. This task is a safety priority to ensure the infant's postoperative care and prevent any complications related to the surgical correction. It requires immediate attention to prevent injury or complications. Choices A, B, and C are important tasks but not as urgent as ensuring the safety and well-being of a postoperative infant. Collecting a stool sample, engaging a toddler in play, and washing the hair of an adolescent can be done after ensuring the immediate safety and well-being of the postoperative infant.
Question 5 of 5
A nurse is caring for a client who has named a person to serve as his health care proxy. The client states he needs clarification about this type of advance directive. Which of the following statements by the client indicates a need for clarification?
Correct Answer: C
Rationale: The correct answer is C because the statement "I have to choose a family member as my health proxy" is incorrect. The client does not have to choose a family member as their health care proxy; they can choose any trusted individual to act as their proxy. This indicates a need for clarification as the client may be under the misconception that the proxy must be a family member. Statement A is not the correct answer because the client can indeed change their designated health care proxy at any time. Statement B is not the correct answer because end-of-life choices are typically made by the proxy only if the client is unable to make decisions themselves. Statement D is not the correct answer because the health care proxy does go into effect as soon as it is designated, not only when the client is incapable of making decisions.