ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 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.
Question 2 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 3 of 5
Which of the following is an example of a nursing diagnosis?
Correct Answer: D
Rationale: Ineffective breathing pattern is a standardized NANDA nursing diagnosis, addressing altered respiratory function.
Question 4 of 5
Which action is the priority when providing care to a patient in the preoperative period?
Correct Answer: B
Rationale: The checklist ensures all critical preoperative steps are completed.
Question 5 of 5
A nurse is assigned to care for four clients. Which client should the nurse assess first?
Correct Answer: D
Rationale: While it is important to prepare the postoperative client for discharge and ensure they understand how to take their new medication, this situation is less urgent than addressing a potential respiratory issue. Changing the dressing on a recent surgical incision is part of routine care and can be scheduled after more urgent needs are addressed. The client’s wound care is important, but it does not take precedence over potential respiratory distress. Although the chest x-ray is necessary to confirm the correct placement of the nasogastric tube, this can be done after the more immediate concern of a respiratory issue is addressed. The nasogastric tube will remain in place for feeding or drainage in the meantime. This client should be assessed first because asthma can lead to respiratory distress or an asthma attack, which requires prompt intervention. Since the client requested a nebulizer treatment during the previous shift, it is crucial to assess their current respiratory status and administer the treatment if necessary to prevent any complications.