ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?
Correct Answer: D
Rationale: Obtaining a routine urine sample from a newly-admitted client is an important task for the nurse to delegate to assistive personnel (AP). While this is essential for assessing the client's baseline health status and planning further care, it is not as urgent as taking an arterial blood gas specimen to the laboratory, which is time-sensitive. Passing fresh water to clients on the unit is an essential routine task to ensure clients stay hydrated. However, this task does not have the same level of urgency compared to taking an arterial blood gas specimen to the laboratory. This can be done after more critical tasks are completed. Transporting a client to the radiology department for an x-ray is a necessary step in diagnostic imaging, but it does not carry the same level of urgency as taking an arterial blood gas specimen to the laboratory. Arterial blood gas results are critical for evaluating and managing a client's respiratory and metabolic status. Taking an arterial blood gas (ABG) specimen to the laboratory is a top priority because the results are time-sensitive and crucial for the immediate assessment and management of a client's respiratory and metabolic function. Delaying this task could impact the timely diagnosis and treatment of potentially serious conditions, making it the most urgent task to delegate first.
Question 2 of 5
The emergency department nurse is triaging clients arriving from a mass casualty incident. During the triage, the nurse confirms that each client has a disaster tag. What information should be placed on the tag for each client? (Select all that apply)
Correct Answer: A,B,C,D,E
Rationale:
Choice A reason: Including client information on the disaster tag is crucial for identification and tracking purposes. This information ensures that each client can be accurately identified, which is essential for providing appropriate care and for communication with family members and other healthcare providers.
Choice B reason: Triage priority is an essential piece of information that indicates the level of urgency for each client's care. This prioritization helps healthcare providers quickly identify which clients need immediate attention and which can wait, thereby optimizing the use of limited resources during a mass casualty incident.
Choice C reason: Next of kin information is important for contacting family members and loved ones in case of emergency. This information is essential for communicating the client's status, obtaining additional medical history, and providing support to the family during a stressful time.
Choice D reason: Decontamination information, if applicable, indicates whether the client has undergone decontamination procedures. This is critical for ensuring that contaminated clients do not pose a risk to others, including healthcare providers and other patients, and for maintaining a safe environment within the healthcare facility.
Choice E reason: Documenting medications and treatments administered is vital for continuity of care. This information allows healthcare providers to track what treatments have been given, avoid duplication of medications, and monitor the client's response to treatment. It also ensures that any subsequent healthcare providers have a complete record of the client's care.
Question 3 of 5
The flight nurse arrived on scene of a bomb explosion and is assisting in the triage of clients. The client is found lying on the ground, confused but obeying commands. The client has a deformity to his lower leg with good peripheral pulses but is unable to ambulate. Using the START triage, what acuity level should be assigned to this client?
Correct Answer: A
Rationale: In the START triage system, the yellow category is designated for clients who are unable to walk, but their condition is stable and does not require immediate life-saving intervention. This client, though confused, is obeying commands, has a deformity to his lower leg with good peripheral pulses, and is unable to ambulate. These factors indicate that the client's injuries need attention but are not immediately life-threatening, making the yellow category appropriate. The black category is for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client does not fall into this category as he is responsive and his condition is stable. The red category is assigned to clients who require immediate life-saving intervention. Although the client is unable to walk and has a deformity to his lower leg, he is stable, obeys commands, and has good peripheral pulses. Thus, he does not meet the criteria for the red category. The green category is used for clients who can walk and have minor injuries that do not require urgent medical attention. This client is unable to ambulate, indicating that his condition is more serious than those in the green category.
Question 4 of 5
A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Assessing the lethality of the plan helps determine the immediate risk and guides intervention.
Question 5 of 5
A nurse working at an assisted living facility is helping emergency medical services (EMS) triage clients after a fire in the building. The 83-year-old client suffered smoke inhalation. The client is coughing with a respiratory rate of 36 and reports shortness of breath. Using the START triage, what acuity level should be assigned to this client?
Correct Answer: C
Rationale: The black category in the START triage system is for clients who are deceased or have injuries so severe that they are not expected to survive even with immediate medical intervention. This client is not in that category since they are conscious and breathing. The green category is for clients who are ambulatory with minor injuries and do not require urgent medical attention. This client is experiencing significant respiratory distress, which categorizes them as more urgent. The red category is for clients who need immediate life-saving intervention. This client's respiratory rate of 36 and shortness of breath indicate a severe respiratory distress that requires urgent medical attention. The yellow category is for clients who are unable to walk but have stable conditions that do not require immediate life-saving intervention. This client's condition is more severe and needs prompt intervention.