ATI RN
Client Safety Nursing Questions
Question 1 of 5
Which arterial blood gas (ABG) result is most consistent with early-stage ARDS?
Correct Answer: B
Rationale: The correct answer is B (pH 7.45, PaCO2 30 mm Hg, PaO2 55 mm Hg) as it indicates early-stage ARDS. In ARDS, there is hypoxemia, resulting in low PaO2 levels. The low PaO2 can lead to respiratory alkalosis, hence the high pH (normal or slightly alkalotic). The low PaCO2 (hypocapnia) is a compensatory mechanism to maintain pH. Choices A, C, and D do not reflect the typical ABG findings in early-stage ARDS. A (pH 7.30, PaCO2 50 mm Hg, PaO2 60 mm Hg) shows respiratory acidosis and lower PaO2. C (pH 7.38, PaCO2 40 mm Hg, PaO2 92 mm Hg) indicates better oxygenation and less likely to be early ARDS. D (
Question 2 of 5
The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Obtain oxygen saturation using pulse oximetry. In a patient with sepsis, it is crucial to assess oxygen saturation to evaluate respiratory status and tissue perfusion. The patient's vital signs indicate signs of respiratory distress (elevated temperature, increased respirations) and potential hypoperfusion (low blood pressure). Oxygen saturation will provide critical information on the patient's oxygenation status. A: Notifying the healthcare provider may be necessary but addressing the immediate respiratory concern is the priority. C: Documenting and monitoring are important, but immediate intervention is needed due to the patient's critical condition. D: Administering acetaminophen is not appropriate at this time as the priority is to assess and address respiratory distress and potential hypoperfusion.
Question 3 of 5
A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS?
Correct Answer: C
Rationale: The correct answer is C: white-out infiltrates bilaterally. In acute respiratory distress syndrome (ARDS), chest x-ray typically shows diffuse bilateral infiltrates leading to a "white-out" appearance due to severe inflammation and fluid accumulation in the lungs. This finding is indicative of ARDS as it reflects the hallmark feature of widespread alveolar damage and edema. Explanation for incorrect choices: A: Infiltrates only on the upper lobes do not align with the diffuse bilateral involvement seen in ARDS. B: Enlargement of the heart with bilateral lower lobe infiltrates suggests congestive heart failure rather than ARDS. D: A normal chest x-ray would not be expected in a patient suspected of having ARDS, as there would be significant pathological changes present in the lungs.
Question 4 of 5
A charge nurse has access to the facility's electronic client records. It is appropriate for the charge nurse to share her personal password with whom?
Correct Answer: B
Rationale: The correct answer is B: No one. Sharing personal passwords violates confidentiality and security protocols. The charge nurse is responsible for safeguarding client information and should not share her password with anyone, including the nurse manager, nursing student, or unit clerk. Sharing passwords can lead to unauthorized access to sensitive data, compromising client privacy and violating HIPAA regulations. It is essential to maintain individual accountability for accessing electronic records to ensure data integrity and protect client confidentiality.
Question 5 of 5
Following a tornado, a nurse is determining which of the clients assigned to her care can be discharged to free up beds for injured clients. Which of the following clients should the nurse recommend for discharge?
Correct Answer: A
Rationale: The correct answer is A. The young adult client with Crohn's disease preoperative for an ileostomy can be recommended for discharge as the surgery is planned and stable. - Choice B: The adolescent with a spontaneous pneumothorax may need further monitoring and care due to the severity of the condition. - Choice C: The middle adult postoperative from an open laminectomy requires close monitoring for complications and pain management. - Choice D: The older adult with diabetic ketoacidosis and a pH of 7.32 still needs treatment and monitoring for stabilization.