ATI RN
Essentials Of Nursing Client Safety Questions
Question 1 of 5
Which intervention is key to preventing ventilator-associated pneumonia as a complication in a patient with acute respiratory distress syndrome (ARDS)?
Correct Answer: C
Rationale: Rationale for Choice C: Providing frequent mouth care and oral hygiene is key to preventing ventilator-associated pneumonia in ARDS patients. This intervention helps reduce the risk of oral bacteria entering the lungs, which can lead to pneumonia. Maintaining oral hygiene also decreases the colonization of pathogens in the oropharynx, reducing the risk of aspiration. This intervention is supported by evidence-based practice guidelines for preventing ventilator-associated pneumonia. Summary of other choices: A: Scheduled prophylactic nasopharyngeal suctioning is not recommended as a routine preventive measure for ventilator-associated pneumonia in ARDS patients. B: Instilling normal saline down the endotracheal tube can increase the risk of infection and does not address the root cause of ventilator-associated pneumonia. D: Using high tidal volumes on the ventilator can exacerbate lung injury in ARDS patients and is not a preventive measure for ventilator-associated pneumonia.
Question 2 of 5
A nurse is caring for a client on the medical-surgical unit. The client has been taking warfarin at home and her laboratory values reveal her INR is 3.5. The client states she is checking herself out of the hospital and refuses to wait until her provider can discuss the situation with her. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: The correct answer is C. The nurse should explain the risks the client faces if she leaves the facility with a high INR level of 3.5 while on warfarin. This is important because a high INR puts the client at risk for bleeding, which can be life-threatening. By explaining the risks, the nurse is providing the client with crucial information to help her make an informed decision about leaving against medical advice. Choice A is incorrect because forcing the client to sign an AMA form may not be legally appropriate if the client has decision-making capacity. Choice B is incorrect because threatening the client with insurance consequences is not ethical and does not address the immediate health risk. Choice D is incorrect because involving security is not necessary in this situation and does not address the client's medical needs.
Question 3 of 5
A nurse is caring for a client who is preoperative. The nurse signs as a witness on the client's consent form. The nurse's signature on the consent form indicates which of the following?
Correct Answer: B
Rationale: Rationale for Correct Answer B: The nurse's signature on the consent form confirms the client appears competent to provide consent. This is important as it ensures the client has the capacity to make informed decisions about their care. The nurse assesses the client's ability to understand the information provided regarding the procedure and its risks and benefits. By signing as a witness, the nurse acknowledges that the client is mentally competent to provide consent. Summary of Incorrect Choices: A: Incorrect. The nurse's signature does not determine if the client has a mental illness. This falls under the purview of the healthcare provider, not the nurse. C: Incorrect. While the nurse may have explained the risks and benefits, this is not the sole purpose of the nurse's signature on the consent form. D: Incorrect. The nurse's signature does not indicate the client's spouse agrees with the procedure; this is not the nurse's role in the consent process.
Question 4 of 5
A nurse is preparing an in-service for an annual skills fair at a community medical facility about fire safety. Place the steps in the order in which they should be performed in the case of a fire emergency.
Correct Answer: D
Rationale: Correct Answer: D (Rescue the clients) Rationale: In a fire emergency, the top priority is to ensure the safety of individuals by rescuing them. Once the clients are safe, the nurse can proceed to other steps like pulling the fire alarm, confining the fire, and extinguishing it. By rescuing the clients first, the nurse minimizes the risk of harm and ensures everyone's safety. Summary of Incorrect Choices: A (Pull the fire alarm): While important, pulling the fire alarm should come after rescuing the clients to alert others and initiate the fire safety protocol. B (Confine the fire): Confining the fire is crucial but should be done after ensuring everyone's safety through rescue. C (Extinguish the fire): Extinguishing the fire is essential, but it should not be the first step as the priority is to rescue individuals from harm.
Question 5 of 5
A nurse is delegating morning vital signs to an assistive personnel (AP). What action should the nurse take?
Correct Answer: B
Rationale: The correct answer is B because determining the time frame for reporting results is crucial in ensuring timely and effective communication of vital signs data. This step allows the nurse to promptly address any abnormal findings or changes in the patient's condition. A: Verifying the AP's educational preparation is important but not directly related to delegating morning vital signs. C: Observing the AP obtaining vital signs can be helpful for initial training but may not be necessary for every instance of delegation. D: Asking the AP to take vital signs of a post-surgery client first is not the most appropriate action as prioritization should be based on patient acuity, not the type of surgery.