ATI RN
Client Health and Safety Responsibilities Questions
Question 1 of 5
Which assessment finding should cause the nurse to suspect the early onset of hypoxemia?
Correct Answer: A
Rationale: The correct answer is A: Restlessness. Restlessness is an early sign of hypoxemia due to the body's attempt to increase oxygen intake. Hypotension (B) is a late sign in hypoxemia. Central cyanosis (C) is a late sign when the lips and mucous membranes appear blue. Cardiac dysrhythmias (D) are also a late sign in hypoxemia due to inadequate oxygen supply to the heart. Restlessness is the earliest indicator of hypoxemia compared to the other options.
Question 2 of 5
When the nurse is caring for an obese patient with left lower-lobe pneumonia, gas exchange will be best when the patient is positioned
Correct Answer: B
Rationale: The correct answer is B: on the right side. When the patient with left lower-lobe pneumonia is positioned on the right side, gravity helps drain secretions from the affected area, improving ventilation and gas exchange. Placing the patient on the left side (A) may worsen oxygenation by further compromising the already affected lobe. High-Fowler's position (C) may not be as effective in promoting drainage as side-lying positions. The tripod position (D) is commonly used for patients with respiratory distress, but in this case, side positioning is more beneficial for improving gas exchange in the specific affected area.
Question 3 of 5
A nurse walks in to a client who is in respiratory distress. The client has tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures?
Correct Answer: B
Rationale: The correct answer is B: Chest tube insertion on the left side. Tracheal deviation to the right side indicates tension pneumothorax, where air accumulates in the pleural space, displacing the mediastinum and trachea. Inserting a chest tube on the left side will decompress the pneumothorax, restoring normal breathing. Option A is incorrect because the chest tube should be inserted on the side opposite the deviation. Option C, intubation, is not the first-line treatment for tension pneumothorax. Option D, tracheostomy, is not indicated in this emergent scenario.
Question 4 of 5
The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur?
Correct Answer: C
Rationale: The correct answer is C: The client will be placed back on full ventilatory support. Based on the assessment findings of a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles, the client is showing signs of respiratory distress and not tolerating CPAP. The nurse should anticipate that the client will require full ventilatory support to manage their respiratory status effectively. Increasing FiO2 (choice A) may not be sufficient to address the underlying issue. Weaning should not continue (choice B) as the client is not tolerating CPAP. Extubation (choice D) is not appropriate given the client's current respiratory status.
Question 5 of 5
A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate?
Correct Answer: B
Rationale: The correct answer is B: 'What do you think your spouse would have wanted?' Rationale: 1. This response shows empathy and respect for the spouse's feelings and autonomy. 2. It allows the spouse to reflect on the wishes and values of the brain-dead client. 3. It helps the spouse make a decision based on what the client would have wanted, rather than external pressures. Incorrect choices: A: A shortage of organs is not a valid reason to pressure the spouse into donating organs. C: Bringing up religion may only add unnecessary complexity to an already difficult decision. D: Emphasizing personal feelings may guilt-trip the spouse into making a decision that may not align with the client's wishes.