ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 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 2 of 5
The nurse is working on the step-down unit and receives the shift-to-shift report on four clients. Based on the report information, which client would be the highest priority to assess first?
Correct Answer: C
Rationale: A 32-year-old male with a femur fracture in traction is stable but needs ongoing pain management and monitoring for complications like infection or deep vein thrombosis (DVT). While this client requires attention, they are not in immediate critical condition compared to other patients on the list. A 38-year-old female with a grade 1 liver laceration admitted 2 days ago also requires close observation for signs of bleeding or worsening liver function. However, given that the liver laceration is of a lesser severity (grade 1), the immediate priority is less critical compared to a client with respiratory compromise. A 41-year-old male with 4 rib fractures, pneumothorax, and a chest tube is the highest priority. The presence of pneumothorax indicates a potential life-threatening condition that requires close monitoring to ensure the chest tube is functioning correctly and the lung is re-expanding. Any compromise in the chest tube's functionality can lead to respiratory distress or failure, making this client the most critical and requiring immediate assessment. A 55-year-old female admitted 6 days ago with a chest contusion and scheduled for discharge today is likely stable and does not have the same level of urgency as a client with a pneumothorax. This client needs final evaluations and discharge planning, but their condition does not present an immediate life-threatening risk.
Question 3 of 5
Which symptoms would the nurse expect to assess in a client experiencing serotonin syndrome?
Correct Answer: D
Rationale: Serotonin syndrome involves mental status changes, autonomic instability, and neuromuscular abnormalities.
Question 4 of 5
A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis?
Correct Answer: C
Rationale: Diarrhea causes excessive bicarbonate loss, leading to metabolic acidosis.
Question 5 of 5
The nurse is assessing a newly admitted client who appears upset and agitated. What would be the best action for the nurse to best assist this client?
Correct Answer: C
Rationale: Arranging for the client to remain on bedrest may not address the underlying reasons for the client's upset and agitation. While physical rest can be beneficial, it is more important to address the client's emotional and psychological needs through communication and support. Telling the client to remain calm can be perceived as dismissive and may not effectively alleviate their distress. It is important for the nurse to acknowledge the client's feelings and provide a supportive environment for them to express themselves. Encouraging the client to share their feelings is the best action to assist the client. By providing a supportive and empathetic environment, the nurse can help the client express their emotions, identify the cause of their distress, and work together to find appropriate solutions. This approach promotes therapeutic communication and can lead to a more accurate assessment and effective care plan. Giving the client time to rest and returning later for the assessment may delay addressing the client's immediate emotional needs. It is important for the nurse to engage with the client promptly to understand their concerns and provide support.