ATI RN
Client Safety Basic Concept Template Questions
Question 1 of 5
Who is responsible for admission sheet?
Correct Answer: B
Rationale: Doctors oversee initial patient assessments and documentation.
Question 2 of 5
A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Ensure an x-ray is completed to confirm placement. This is the next crucial step to ensure the central venous access line is correctly positioned before any infusion is initiated. This step helps prevent complications such as catheter misplacement, which can lead to serious issues like pneumothorax or vessel perforation. Checking medication calculations with another RN (C) is important but not the immediate next step. Beginning the infusion (A) without confirming proper placement can be dangerous. Ensuring the solution is appropriate (D) is also important but secondary to confirming placement.
Question 3 of 5
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?
Correct Answer: D
Rationale: The correct answer is D: Infection. The client's symptoms of abdominal pain and feeling warm are indicative of a potential infection, which is a common complication of intraperitoneal therapy. The nurse should assess for signs of infection such as fever, chills, redness, or drainage at the catheter site. Prompt intervention is crucial to prevent further complications. A: Allergic reaction - This is unlikely based on the client's symptoms and the timing of starting the therapy 5 days ago. B: Bowel obstruction - This is not a typical complication of intraperitoneal therapy and doesn't align with the client's symptoms. C: Catheter lumen occlusion - While this is a possible complication, the symptoms described by the client are more indicative of an infection rather than catheter occlusion.
Question 4 of 5
A client diagnosed with paranoid schizophrenia states, "My psychiatrist is out to get me. I'm sad that the voice is telling me to stop him." What symptom is the client exhibiting, and what is the nurse's legal responsibility related to this symptom?
Correct Answer: C
Rationale: The correct answer is C: Command hallucinations; warn the psychiatrist. The client is experiencing command hallucinations, as they are hearing voices instructing them to harm their psychiatrist. The nurse's legal responsibility is to ensure the safety of the client and others. By warning the psychiatrist, the nurse can help prevent any potential harm. Administering medication (A) may be necessary but does not directly address the safety concern. Orienting the client to reality (B) may not be effective given the severity of the hallucinations. Calling an emergency treatment team meeting (D) may be appropriate, but the immediate action should be to warn the psychiatrist to ensure safety.
Question 5 of 5
A client states, "I hear voices that tell me that I am evil." Which outcome related to these symptoms should the nurse expect this client to accomplish by discharge?
Correct Answer: C
Rationale: The correct answer is C because identifying events that trigger anxiety and hallucinations is a crucial step in managing auditory hallucinations. By recognizing these triggers, the client can develop coping strategies to reduce anxiety and potentially decrease the frequency or intensity of the voices. A is incorrect because verbalizing the reason for the derogatory statements does not address the underlying triggers causing the hallucinations. B is incorrect because completely eliminating auditory hallucinations is often a challenging goal and may not be realistic for all clients. D is incorrect because integrating hallucinations into one's personality structure is not a recommended or evidence-based approach in mental health practice.