ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
A nurse receives a shift report on the following clients. Which client should the nurse prioritize first?
Correct Answer: C
Rationale: A client who has undergone a cholecystectomy 2 days ago with decreased bowel sounds might be experiencing a common postoperative issue that requires monitoring but may not need immediate intervention. Decreased bowel sounds can result from the effects of anesthesia, pain medications, or the surgical procedure itself. While this condition warrants attention, it is not as urgent as new-onset confusion in another client. A client with diabetes mellitus and a blood glucose level of 140 mg/dL is within a manageable range, especially in a hospitalized setting. This level of blood glucose does not indicate immediate danger and can be managed with appropriate insulin or oral medication adjustments. It is important for maintaining overall glucose control, but it does not present an urgent situation requiring immediate prioritization over the other clients. A client with a left femur fracture experiencing new-onset confusion is the highest priority. New-onset confusion can be a sign of several serious conditions, such as delirium, infection, or a complication related to the fracture or its treatment. This symptom indicates an acute change in the client's condition that requires immediate assessment and intervention to determine the underlying cause and prevent further complications.
Therefore, this client should be prioritized first. A client admitted for dehydration with a blood pressure of 105/77 mm Hg has a relatively stable blood pressure reading. While dehydration requires prompt treatment with fluids, this client's condition is not as critical as the client experiencing new-onset confusion. The blood pressure reading indicates that the client is maintaining an adequate circulatory status and can be managed after addressing the more urgent needs of the client with confusion.
Question 2 of 5
The nurse working on the medical-surgical unit has delegated several patient care tasks to the unlicensed assistive personnel. What is the nurse's primary responsibility after the delegation of tasks?
Correct Answer: C
Rationale: Assigning tasks that were not completed to the next nursing shift is a part of shift change protocols but is not the primary responsibility after delegating tasks. Follow-up is crucial to ensure that all tasks are completed correctly and on time. Allowing each staff member to judge if the task needs to be completed undermines the importance of the tasks and could lead to inconsistencies in patient care. It is essential to follow up and ensure that the tasks are completed as delegated. Following up with each staff member regarding the performance and outcome of each task is critical. This ensures that the tasks are completed correctly, provides an opportunity to address any issues, and reinforces accountability in the team. Documenting that the task was completed is important, but it should occur after the nurse has confirmed that the task was performed correctly. Follow-up is essential to verify the accuracy and completeness of the delegated tasks before documentation.
Question 3 of 5
The nurse is caring for a client being prepared for a left total knee replacement surgery. The nurse is witnessing the surgeon obtain informed consent before the procedure. Which essential components must be present to obtain informed consent? (Select all that apply)
Correct Answer: A,B,C,D,E
Rationale:
Choice A reason: Informing the client when the procedure or treatment will be done is crucial for obtaining informed consent. This information helps the client understand the timeline and schedule for the procedure, which is essential for their planning and mental preparation. Knowing the exact date and time also allows the client to arrange for any necessary assistance or support they might need before and after the procedure.
Choice B reason: The purpose of the proposed treatment or procedure must be clearly explained to the client. This information helps the client understand why the procedure is necessary and what it aims to achieve. Providing a clear rationale for the treatment ensures that the client is fully aware of the medical reasons behind the procedure, which is a fundamental aspect of informed consent.
Choice C reason: The expected outcomes of the proposed treatment or procedure should be discussed with the client. This includes both the potential benefits and the goals of the treatment. By understanding the expected outcomes, the client can make an informed decision about whether to proceed with the procedure, weighing the potential benefits against the risks and alternatives.
Choice D reason: Identifying who will perform the treatment or procedure is an essential component of informed consent. The client has the right to know the qualifications and expertise of the healthcare professional who will be performing the procedure. This information helps build trust and ensures the client feels confident in the care they will receive.
Choice E reason: An explanation of the possible risks from the treatment or procedure is necessary for obtaining informed consent. Clients must be fully informed about the potential risks and complications associated with the procedure so that they can make an educated decision about whether to proceed. This transparency is critical for respecting the client's autonomy and ensuring they are fully aware of all aspects of their care.
Question 4 of 5
The nurse is reviewing the laboratory results for a client who is scheduled for knee arthroplasty later in the day. Which laboratory value is most important to report to the health care provider before the surgery?
Correct Answer: B
Rationale: A hematocrit level of 33.4% is slightly below the normal range, which may indicate mild anemia. While this is important to monitor, it is not as urgent as a high white blood cell count, which could indicate an infection. Mild anemia can typically be managed perioperatively without significant risk. A white blood cell count of 15.5 x10/uL is significantly elevated and suggests an active infection or inflammatory process. Before proceeding with surgery, it is crucial to identify and treat any infections to prevent postoperative complications, such as sepsis. This value is the most critical to report to the healthcare provider to ensure the safety of the surgical procedure. A platelet count of 386,000 mm³ is within the normal range and does not indicate any immediate risk of bleeding or clotting disorders. Thus, this value does not necessitate urgent reporting before surgery. A hemoglobin level of 12.2 g/dL is at the lower end of the normal range, indicating borderline anemia. Although it is important to consider, it does not present as immediate a concern as a potential infection. The surgery can generally proceed with closer monitoring of the client's hemoglobin levels.
Question 5 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.