ATI Nur 175 Med Surg Exam | Nurselytic

Correct Answer: A

Rationale: An incident report is necessary when a client discovers that his dentures are missing. This situation involves a loss of personal property and could potentially lead to further complications, such as the client being unable to eat properly or experiencing distress. Documenting the incident ensures proper follow-up and resolution. While identifying a broken piece of equipment is important and should be addressed, it does not typically require an incident report unless the equipment failure has directly caused harm or posed a significant risk to a client or staff member. Reporting the issue through maintenance channels is usually sufficient. A disagreement between the nurse and the nursing supervisor about staffing is an internal issue that should be addressed through appropriate channels such as team meetings or discussions with management, rather than an incident report. A staff member not showing up for their assigned shift is a staffing issue that should be managed through scheduling and human resources processes. It does not typically warrant an incident report unless it directly leads to an adverse event affecting client care.

Correct Answer: B

Rationale: The red category in the START triage system is assigned to clients who require immediate life-saving intervention. Although this client is in pain and has severe symptoms, their respiratory rate, pulse, and capillary refill are normal, indicating that they do not need immediate life-saving intervention. The yellow category is designated for clients whose condition is stable but requires observation. This client is awake, alert, and oriented, with a normal respiratory rate, good radial pulse, and normal capillary refill. While they have severe abdominal pain and nausea, their condition does not appear to be life-threatening, making yellow the appropriate triage level. The black category is used 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 stable and responsive, so they do not fall into this category. The green category is for clients with minor injuries who can walk and do not require urgent medical attention. Since this client has severe symptoms and needs medical attention, the green category is not appropriate.

Correct Answer: D

Rationale: These six steps encompass the complete nursing process.

Correct Answer: C

Rationale: A 32-year-old male with a femur fracture in traction is stable but needs ongoing pain management and monitoring for complications like infection or deep vein thrombosis (DVT). While this client requires attention, they are not in immediate critical condition compared to other patients on the list. A 38-year-old female with a grade 1 liver laceration admitted 2 days ago also requires close observation for signs of bleeding or worsening liver function. However, given that the liver laceration is of a lesser severity (grade 1), the immediate priority is less critical compared to a client with respiratory compromise. A 41-year-old male with 4 rib fractures, pneumothorax, and a chest tube is the highest priority. The presence of pneumothorax indicates a potential life-threatening condition that requires close monitoring to ensure the chest tube is functioning correctly and the lung is re-expanding. Any compromise in the chest tube's functionality can lead to respiratory distress or failure, making this client the most critical and requiring immediate assessment. A 55-year-old female admitted 6 days ago with a chest contusion and scheduled for discharge today is likely stable and does not have the same level of urgency as a client with a pneumothorax. This client needs final evaluations and discharge planning, but their condition does not present an immediate life-threatening risk.

Correct Answer: A

Rationale: This statement is a priority because testosterone therapy can significantly impact fertility. Clients should be informed about the potential effects on their reproductive health, including the possibility of reduced fertility or infertility. This knowledge allows them to make informed decisions about fertility preservation before starting hormone therapy. While an increase in muscle mass is a common and expected effect of testosterone therapy, it is not as critical as discussing the potential impact on fertility. Increased muscle mass is generally seen as a desired outcome for transgender men undergoing hormone therapy. Acne is a known side effect of testosterone therapy, but it is not as high of a priority compared to the long-term implications of fertility. Acne can be managed with appropriate skincare and treatment. Changes in emotion or mood can occur with hormone therapy, but they are generally considered part of the overall effects of transitioning. These changes are important to monitor but are not as immediately critical as the impact on fertility.