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
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 3 of 5
A client has a diagnosis of risk for suicide r/t a past attempt. Which of the following outcome should the nurse prioritize?
Correct Answer: D
Rationale: Preventing self-harm is the top priority for suicide risk.
Question 4 of 5
The nurse is eating lunch in the hospital cafeteria, which is crowded with visitors and other staff. A health care provider approaches the nurse and asks, 'How is my client Ms. Jones in room 312 doing?' Which response by the nurse would be most appropriate?
Correct Answer: A
Rationale: This response is appropriate because it maintains client confidentiality by suggesting to move away from the crowded area before discussing private information. It shows respect for the client's privacy and adheres to HIPAA regulations. While this response directs the health care provider to the appropriate person, it does not address the immediate need for privacy. It is important to ensure that any discussion about the client is done in a confidential manner. This response is not ideal because it can come across as dismissive and does not offer to address the situation appropriately. Ensuring client confidentiality should remain a priority even if the nurse is off duty. This response violates client confidentiality by sharing information about the client's condition in a public setting. It is crucial to discuss such details in a private area to protect the client's privacy.
Question 5 of 5
Which nursing action is completed during phase III of post anesthesia care?
Correct Answer: A
Rationale: Phase III focuses on preparing the patient for discharge, including teaching.