ATI RN
Client Safety Alternatives to Restraints Quizlet Questions
Question 1 of 5
You, the nurse, have been monitoring the client with subcutaneous emphysema around the shoulder and lower neck. You notice that the area has expanded and is traveling up the neck. Based on your knowledge, what should the nurse anticipate doing in the near future?
Correct Answer: D
Rationale: The correct answer is D: Assisting with tracheostomy insertion. Subcutaneous emphysema traveling up the neck indicates potential airway compromise. Tracheostomy insertion may be necessary to secure the airway and prevent further complications. Surgery (choice A) may not address the immediate need for securing the airway. Encouraging the client to use the Incentive Spirometer (IS) (choice B) or palpating the area (choice C) would not address the urgency of the situation or provide a definitive solution to the airway compromise.
Question 2 of 5
A nurse is participating in a disaster simulation in which a toxic substance is released into a crowded stadium. Multiple clients are transported to the facility. Which of the following activities would be the lowest priority for the nurse?
Correct Answer: C
Rationale: The correct answer is C. Transferring a client to the discharge location would be the lowest priority for the nurse during a disaster simulation. Priority should be given to immediate actions that ensure the safety and well-being of all clients. Here's a step-by-step rationale: 1. Preventing cross-contamination (choice A) is crucial to prevent the spread of the toxic substance. 2. Performing concise client assessment (choice B) is essential to identify and prioritize care for clients based on their needs. 3. Maintaining a client tracking system (choice D) is vital for ensuring accountability and continuity of care. 4. Transferring a client to the discharge location (choice C) can be delayed as it is not immediately life-threatening or crucial for the initial response.
Question 3 of 5
A nurse is planning client care for herself and an assistive personnel (AP). Which task should the nurse plan to perform?
Correct Answer: C
Rationale: The correct answer is C: Assessing a client's sacrum for edema. The nurse should plan to perform this task as it requires clinical judgment and assessment skills, which are within the scope of nursing practice. The nurse can identify early signs of skin breakdown and provide appropriate interventions. Explanation of other choices: A: Administration of an enema - This task can be safely delegated to an assistive personnel as long as the client's condition is stable. B: Application of antiembolic stockings - This task does not require clinical judgment and can be delegated to an assistive personnel. D: Assisting a client to cough and deep breathe - This task can be delegated to an assistive personnel as long as the client's condition is stable.
Question 4 of 5
A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict?
Correct Answer: A
Rationale: Step 1: The charge nurse needs to address the issue directly and professionally with the staff nurse. Step 2: Statement A is the correct choice as it focuses on discussing unit expectations regarding delegation and task completion. Step 3: This approach promotes open communication, sets clear expectations, and provides an opportunity for improvement. Step 4: Option B is incorrect as it involves hearsay and does not address the issue directly. Step 5: Option C is not the best approach as it uses a threatening tone instead of fostering a constructive dialogue. Step 6: Option D is judgmental and accusatory, which can escalate the conflict instead of resolving it. Step 7: By choosing statement A, the charge nurse can effectively address the situation and guide the staff nurse towards better delegation and task completion practices.
Question 5 of 5
A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?
Correct Answer: A
Rationale: The correct answer is A: Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. This task should be completed first because monitoring blood glucose levels is essential for clients with diabetes who are on short-acting insulin to prevent hypoglycemia. Timely monitoring allows the nurse to assess the client's current glucose level and adjust the insulin dose if needed before the client eats breakfast. Choice B is incorrect because applying a condom catheter to an incontinent client is important but not as time-sensitive as blood glucose monitoring for a client on short-acting insulin. Choice C is incorrect because while feeding a client with bilateral casts is important for nutrition and comfort, it is not as time-sensitive as monitoring blood glucose levels for a client on short-acting insulin. Choice D is incorrect because delivering a clean voided urine specimen to the laboratory is important for diagnostic purposes, but it is not as time-sensitive as monitoring blood glucose levels for a client on short-acting