ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
When designing a plan for pain management for a postoperative patient, the nurse assesses that the patient's priority is to be as free of pain as possible. The nurse and patient work together to identify a plan to manage the pain. The nurse continually reviews the plan with the patient to ensure that the patient's priority is met. Which principle is used to encourage the nurse to monitor the patient's response to the pain?
Correct Answer: A
Rationale: Correct Answer: A: Fidelity Rationale: 1. Fidelity refers to the nurse's duty to uphold the patient's best interests and maintain trust. 2. By continually reviewing the pain management plan with the patient, the nurse demonstrates fidelity by ensuring the patient's priority of being free of pain is met. 3. Monitoring the patient's response to pain aligns with fidelity as it shows the nurse's commitment to the patient's well-being and trust. 4. Fidelity promotes a therapeutic nurse-patient relationship based on honesty and loyalty. Summary of Incorrect Choices: B: Beneficence - Focuses on doing good for the patient, but does not specifically address the nurse's duty to monitor and uphold the patient's priority of pain management. C: Nonmaleficence - Focuses on avoiding harm, but does not specifically address the nurse's role in monitoring and ensuring the patient's priority of pain management. D: Respect for autonomy - Focuses on respecting the patient's right to make
Question 2 of 5
A patient with ARDS is being mechanically ventilated. The physician has ordered prone positioning. What is the primary reason for this intervention?
Correct Answer: D
Rationale: The correct answer is D. Prone positioning helps recruit collapsed alveoli by redistributing ventilation to dependent lung regions, improving oxygenation in ARDS. It enhances lung homogeneity and reduces stress on the dorsal lung regions. Choices A, B, and C are incorrect because prone positioning primarily aims to optimize oxygenation by improving lung ventilation and perfusion, rather than solely reducing diaphragm workload, enhancing perfusion to anterior lung segments, or mobilizing secretions.
Question 3 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 4 of 5
After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with
Correct Answer: D
Rationale: The correct answer is D, inserting a pulmonary artery catheter. This is the most appropriate action to differentiate between ARDS and pulmonary edema caused by left ventricular failure. The pulmonary artery catheter can provide valuable information such as pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac output. In ARDS, the pulmonary artery pressure and pulmonary capillary wedge pressure are typically low, whereas in pulmonary edema due to left ventricular failure, these pressures are elevated. Positioning the patient for a chest radiograph (A) would provide anatomical information but not differentiate between ARDS and pulmonary edema. Drawing blood for arterial blood gases (B) can provide information on oxygenation but may not be sufficient to differentiate between the two conditions. Obtaining a ventilation-perfusion scan (C) is not typically used to differentiate between ARDS and pulmonary edema.
Question 5 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.