ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor asks the nurse
Correct Answer: C
Rationale:
Choice A reason: This response inappropriately shifts the focus to the friend's relationship with the client and implies personal judgment about the client's situation. It also indirectly discloses confidential information by suggesting the client is struggling, which violates client confidentiality.
Choice B reason: This response violates client confidentiality by sharing information about the client's progress, even if framed as reassurance. Disclosing any details about a client's treatment or status without consent is unethical and against legal standards like HIPAA.
Choice C reason: This is the most appropriate response because it clearly and professionally maintains client confidentiality. The nurse firmly states that they cannot discuss any client situation, protecting the client's privacy without being dismissive or confrontational. This response aligns with ethical and legal standards. While this response avoids sharing confidential information, it could be perceived as dismissive or confrontational. A more professional and neutral response, like option C, better upholds confidentiality while maintaining a respectful tone.
Question 2 of 5
Which of the following medications can cause serotonin syndrome?
Correct Answer: C
Rationale: Venlafaxine, an SNRI, increases serotonin levels, potentially causing serotonin syndrome.
Question 3 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 4 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 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.