ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse is completing an admission assessment on a client who has been transferred to the unit. The client has a history of falls and confusion. The nurse forgets to initiate any fall risk prevention as indicated by the hospital policy, and later during the shift, the client falls and sustains a wrist fracture. Which legal tort is the nurse at risk for from this situation?
Correct Answer: D
Rationale: Slander refers to spoken defamation of a person's character. Since this situation does not involve any spoken statements that defame the client, slander is not applicable. Malpractice is a specific type of negligence that occurs when a healthcare professional fails to perform their duties to the required standard, resulting in harm to a patient. While closely related, in this scenario, the broader term negligence more accurately describes the failure to follow hospital policy. Battery involves intentional and wrongful physical contact with a person without their consent, causing harm. In this situation, the nurse's failure to prevent the fall is not an intentional act, so battery is not applicable. Negligence occurs when someone fails to take reasonable care to avoid causing injury or loss to another person. In this case, the nurse's failure to initiate fall risk prevention measures, as required by hospital policy, resulted in the client falling and sustaining a wrist fracture, making the nurse at risk for negligence.
Question 2 of 5
Which of the following nursing interventions takes priority with a newly admitted client having suicidal ideations
Correct Answer: D
Rationale: Close, random monitoring prevents self-harm in suicidal clients.
Question 3 of 5
The charge nurse is planning the staff assignment for the day. Which factors should the nurse consider when planning the assignment? (Select all that apply)
Correct Answer: A,B,C,D,E
Rationale:
Choice A reason: The acuity level of the clients is a critical factor to consider when planning staff assignments. Clients with higher acuity levels require more intensive care and monitoring, necessitating a greater allocation of resources and experienced staff. By considering client acuity, the charge nurse can ensure that the most critical patients receive the appropriate level of care and attention, while also balancing the workload among the nursing staff.
Choice B reason: The clustering of the rooms on the unit can significantly impact the efficiency of care delivery. By grouping clients in close proximity, the nurse can minimize the time and effort spent moving between rooms, thus enhancing the ability to respond quickly to client needs. This consideration helps to optimize workflow and improve overall patient care by reducing potential delays.
Choice C reason: Considering both client needs and the staff's needs and abilities ensures that the right personnel are assigned to the appropriate tasks. Matching staff competencies with client requirements maximizes the effectiveness of care delivery. Additionally, taking into account staff preferences and skills can improve job satisfaction and performance, ultimately benefiting the clients.
Choice D reason: The number of anticipated client discharges is an important logistical factor that can affect the day's workflow. Planning for discharges allows the charge nurse to allocate resources for discharge planning, patient education, and follow-up care. It also helps in managing bed availability and preparing for incoming admissions, ensuring a smooth transition for both clients and staff.
Choice E reason: Specific requests from the staff can include preferences for certain shifts, working with particular patients, or avoiding specific tasks. While it may not always be possible to accommodate all requests, considering them when feasible can improve staff morale and cooperation. Addressing staff preferences helps to create a positive work environment, leading to better teamwork and patient outcomes.
Question 4 of 5
The nurse is caring for a hospitalized client who is found lying on the floor next to the bed. After completing the client assessment and notifying the provider, the nurse completes a hospital incident report. Which statements represent correct documentation that should be included in the report? (Select all that apply)
Correct Answer: B,C,E
Rationale:
Choice A reason: The statement 'The client fell out of bed' is an assumption and not an objective observation. Documentation should include only factual information that is observed or measured, rather than conclusions or suppositions.
Therefore, this statement should not be included in the incident report.
Choice B reason: Documenting the client's vital signs is crucial as it provides measurable data about the client's condition at the time of the incident. Recording blood pressure, pulse, and respirations helps to establish a baseline and can be used for future comparison to assess any changes in the client's status after the incident. This is a factual and objective piece of information that is appropriate for the incident report.
Choice C reason: Noting that no bruises or injuries were observed on the client is an important observation. This statement provides an objective assessment of the client's physical condition immediately after the fall, which is critical for ongoing monitoring and care. It helps to document that the client did not sustain visible injuries during the incident.
Choice D reason: The statement 'The client apparently climbed over the side rails unwitnessed' includes speculation and is not based on direct observation. Documentation should avoid including subjective interpretations or assumptions about the events. Only witnessed and factual information should be recorded in the incident report to maintain accuracy and objectivity.
Choice E reason: Reporting that the health care provider was notified of the incident is essential for ensuring continuity of care. This statement documents the communication between the nurse and the provider, which is a critical step in the incident response process. It ensures that appropriate follow-up actions can be taken based on the provider's assessment and recommendations.
Question 5 of 5
The nurse is counseling a new client who identifies as a transgender female and is expressing the desire to start estrogen therapy for their transition. What potential complication will the nurse include in the client teaching?
Correct Answer: B
Rationale: While hormone therapy can have various effects on the body, impaired nutrition is not a common complication associated with estrogen therapy for transgender women. Nutrition-related issues would more likely arise from other factors unrelated to hormone treatment. Estrogen therapy can increase the risk of thrombosis (blood clots). This is a significant potential complication that must be discussed with clients considering estrogen therapy. Blood clots can lead to serious conditions such as deep vein thrombosis, pulmonary embolism, and stroke. Increased risk of bleeding is not a typical complication of estrogen therapy. Hormone therapy for transgender women generally does not affect the body's ability to clot blood in a way that would cause increased bleeding. Constipation is not a common complication of estrogen therapy. Gastrointestinal side effects are generally not a major concern with hormone therapy for transgender women.