ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?
Correct Answer: D
Rationale: The red category in START triage is reserved for clients who need immediate intervention to survive. This includes those with life-threatening injuries such as severe bleeding or airway obstruction. In this scenario, the 10-year-old client is awake, alert, and ambulatory, indicating that their condition is not immediately life-threatening.
Therefore, the red category is not applicable. The green category is used for clients who are able to walk and have minor injuries. While the 10-year-old client is ambulatory, the presence of a headache and neck pain suggests that their injuries might be more severe than minor. The green category would not be appropriate because their symptoms indicate a need for further evaluation and monitoring. The black category is assigned to clients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. The 10-year-old client is awake, alert, and able to walk, which clearly does not align with the criteria for the black category.
Therefore, this category is not suitable for the client's condition. The yellow category in START triage is for clients who require medical attention but their injuries are not immediately life-threatening. Given that the 10-year-old client is reporting a headache and neck pain, there is a potential risk of underlying injury that warrants attention but does not require immediate intervention. Thus, the yellow category is the most appropriate acuity level for this client.
Question 2 of 5
A community health nurse is creating a presentation about mood disorders for a local support group. The nurse should include which of the following as a risk factor for suicide?
Correct Answer: C
Rationale: Job loss is a significant stressor that increases suicide risk.
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 caring for an older adult client who has a terminal illness and is ventilator-dependent. The client is alert and oriented and he wants to discontinue use of the ventilator. The nurse should be aware that continued treatment against the client's wishes is a violation of which of the following ethical principles?
Correct Answer: B
Rationale: Fidelity refers to the principle of keeping promises and being faithful to one's commitments. It involves loyalty and maintaining trust in the nurse-client relationship. While fidelity is important, it is not the most relevant principle in the context of respecting a client's decision to discontinue treatment. Autonomy is the ethical principle that recognizes an individual's right to make their own decisions and choices regarding their healthcare. Respecting a client's autonomy means acknowledging their right to refuse or discontinue treatment, even if the healthcare team disagrees with their decision. In this case, continued treatment against the client's wishes would violate their autonomy. Justice refers to the principle of fairness and equality in the distribution of resources and care. It involves ensuring that all clients receive equitable treatment. While justice is a key ethical principle, it is not the primary issue when considering the client's wish to discontinue ventilator support. Veracity refers to the principle of truthfulness and honesty in communication with clients. It involves providing accurate and complete information to enable clients to make informed decisions. While veracity is essential, it does not directly address the issue of respecting the client's decision to discontinue treatment.
Question 5 of 5
The newly hired nurse educator for the emergency department is reviewing the hospital disaster plan and policies and finds that it has not been reviewed with the staff for 3 years. Which finding would be most important for the nurse educator to address related to the disaster plan?
Correct Answer: C
Rationale: Depleted stockpiles of medications and resuscitation equipment is a critical concern during a disaster, as it can directly impact the ability to provide care. However, this can typically be addressed by restocking and checking inventory regularly. It is not as immediately crucial as ensuring that all staff are trained and prepared to execute the disaster plan. Changes in hospital resources, such as personnel and infrastructure, can affect the execution of a disaster plan. While this is significant, the most pressing issue is ensuring that the new staff, who may be unfamiliar with the disaster protocols, are adequately trained and ready to respond effectively in an emergency. New staff lacking training and practice in using the disaster plan is the most important finding to address. In a disaster, the ability to implement the plan swiftly and effectively can save lives. Untrained staff may not know their roles, how to use equipment, or the procedures to follow, leading to chaos and ineffective response.
Therefore, it is crucial to ensure all staff are familiar with and have practiced the disaster plan. The risk of technologic disasters in surrounding communities is important to consider in the disaster plan. However, the immediate priority within the hospital is to ensure staff are trained and prepared to handle any disaster scenario. Without proper training, even the best-planned responses to technologic disasters may fail.