ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is caring for a client on the medical-surgical unit who is scheduled for a right hip replacement surgery today. While completing the client assessment, the nurse notes the client has periods of intermittent confusion, sometimes forgetting where she is or why she is in the hospital. Consent for surgery has not yet been obtained. What is the priority action?
Correct Answer: B
Rationale: Reassessing the client when the provider arrives to obtain the informed consent may be necessary, but it is not the priority action. The nurse needs to ensure that the provider is aware of the client's current mental status before any attempt to obtain informed consent is made. Notifying the provider of the client's orientation is the priority action. The client's intermittent confusion indicates that she may not have the capacity to provide informed consent. The provider needs to be aware of this to take appropriate steps, such as involving a legal representative or family member, to obtain consent. Calling the nursing supervisor to give consent for the surgery is not appropriate. The nursing supervisor does not have the legal authority to provide consent on behalf of the client. Asking another nurse to witness the informed consent does not address the issue of the client's mental status and ability to provide informed consent. This action is not appropriate given the client's intermittent confusion.
Question 2 of 5
The nurse is working on the medical-surgical unit when a visiting family member reports the sudden onset of a headache and numbness on the left side of their body. The visitor asks the nurse to check their blood pressure. What is the most appropriate response by the nurse?
Correct Answer: A
Rationale: The sudden onset of a headache and numbness on one side of the body are potential signs of a stroke or other serious medical conditions. The most appropriate response is to assist the visitor to the emergency department for immediate evaluation and treatment. Time is critical in such scenarios, and prompt medical attention can significantly impact the outcome. While taking the visitor's blood pressure might provide some information, it is not sufficient to assess the severity of the symptoms. This action alone could delay necessary urgent care. Encouraging the visitor to lie down and see if the symptoms improve is not appropriate because it does not address the potential seriousness of the symptoms. Delaying medical evaluation could worsen the visitor's condition. Advising the visitor to call their primary care provider is not appropriate in this urgent situation. Immediate evaluation in the emergency department is necessary to rule out serious conditions like a stroke.
Question 3 of 5
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
Correct Answer: A
Rationale: An incident report is necessary when a client discovers that his dentures are missing. This situation involves a loss of personal property and could potentially lead to further complications, such as the client being unable to eat properly or experiencing distress. Documenting the incident ensures proper follow-up and resolution. While identifying a broken piece of equipment is important and should be addressed, it does not typically require an incident report unless the equipment failure has directly caused harm or posed a significant risk to a client or staff member. Reporting the issue through maintenance channels is usually sufficient. A disagreement between the nurse and the nursing supervisor about staffing is an internal issue that should be addressed through appropriate channels such as team meetings or discussions with management, rather than an incident report. A staff member not showing up for their assigned shift is a staffing issue that should be managed through scheduling and human resources processes. It does not typically warrant an incident report unless it directly leads to an adverse event affecting client care.
Question 4 of 5
What are the six elements of the nursing process?
Correct Answer: D
Rationale: These six steps encompass the complete nursing process.
Question 5 of 5
The nurse is caring for a client on the medical-surgical unit who is scheduled for a right hip replacement surgery today. While completing the client assessment, the nurse notes the client has periods of intermittent confusion, sometimes forgetting where she is or why she is in the hospital. Consent for surgery has not yet been obtained. What is the priority action?
Correct Answer: B
Rationale: Reassessing the client when the provider arrives to obtain the informed consent may be necessary, but it is not the priority action. The nurse needs to ensure that the provider is aware of the client's current mental status before any attempt to obtain informed consent is made. Notifying the provider of the client's orientation is the priority action. The client's intermittent confusion indicates that she may not have the capacity to provide informed consent. The provider needs to be aware of this to take appropriate steps, such as involving a legal representative or family member, to obtain consent. Calling the nursing supervisor to give consent for the surgery is not appropriate. The nursing supervisor does not have the legal authority to provide consent on behalf of the client. Asking another nurse to witness the informed consent does not address the issue of the client's mental status and ability to provide informed consent. This action is not appropriate given the client's intermittent confusion.