ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 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.
Question 2 of 5
The nurse is working in the emergency department and is receiving multiple clients from a mass casualty incident. The client arrives by ambulance and is awake, alert, and oriented, complaining of severe abdominal pain with nausea and vomiting. The client's respiratory rate is 20 and has a good radial pulse with normal capillary refill. How would you triage this client using the START triage?
Correct Answer: B
Rationale: The red category in the START triage system is assigned to clients who require immediate life-saving intervention. Although this client is in pain and has severe symptoms, their respiratory rate, pulse, and capillary refill are normal, indicating that they do not need immediate life-saving intervention. The yellow category is designated for clients whose condition is stable but requires observation. This client is awake, alert, and oriented, with a normal respiratory rate, good radial pulse, and normal capillary refill. While they have severe abdominal pain and nausea, their condition does not appear to be life-threatening, making yellow the appropriate triage level. The black category is used 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 stable and responsive, so they do not fall into this category. The green category is for clients with minor injuries who can walk and do not require urgent medical attention. Since this client has severe symptoms and needs medical attention, the green category is not appropriate.
Question 3 of 5
The nurse is teaching a class on bioterrorism. What is the scientific rationale for designating a specific area for decontamination?
Correct Answer: B
Rationale: Providing a centralized area for stocking the needed supplies is important for logistical reasons, ensuring that all necessary materials are readily available. However, this is not the primary scientific rationale for designating a specific decontamination area. The primary focus is on preventing contamination and ensuring safety. Preventing secondary contamination to health-care providers is the most crucial reason for designating a specific area for decontamination. This measure is vital to avoid spreading hazardous substances to others and ensuring the safety and effectiveness of the decontamination process. By containing the contamination in a controlled area, health-care providers can minimize the risk of exposure and cross-contamination. Designating an area where bioterrorism clients can receive care is important, but it is not the primary rationale for having a specific decontamination area. While care and treatment are critical, the main goal of the decontamination area is to remove contaminants and protect health-care providers and other patients from exposure. Providing showers and privacy to the client in the decontamination area is beneficial for the comfort and dignity of the client. However, this is not the main scientific rationale for having a designated decontamination area. The primary reason is to control and contain contamination and prevent it from spreading.
Question 4 of 5
A nurse has several tasks to delegate to assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first?
Correct Answer: D
Rationale: Obtaining a routine urine sample from a newly-admitted client is an important task for the nurse to delegate to assistive personnel (AP). While this is essential for assessing the client's baseline health status and planning further care, it is not as urgent as taking an arterial blood gas specimen to the laboratory, which is time-sensitive. Passing fresh water to clients on the unit is an essential routine task to ensure clients stay hydrated. However, this task does not have the same level of urgency compared to taking an arterial blood gas specimen to the laboratory. This can be done after more critical tasks are completed. Transporting a client to the radiology department for an x-ray is a necessary step in diagnostic imaging, but it does not carry the same level of urgency as taking an arterial blood gas specimen to the laboratory. Arterial blood gas results are critical for evaluating and managing a client's respiratory and metabolic status. Taking an arterial blood gas (ABG) specimen to the laboratory is a top priority because the results are time-sensitive and crucial for the immediate assessment and management of a client's respiratory and metabolic function. Delaying this task could impact the timely diagnosis and treatment of potentially serious conditions, making it the most urgent task to delegate first.
Question 5 of 5
The nurse is on her break in the hospital cafeteria when she overhears two nurses talking about a client's condition. The nurse understands this could lead to which of the following complaints?
Correct Answer: B
Rationale: Libel refers to written statements that are false and damaging to a person's reputation. In this scenario, since the nurses are speaking and not writing, libel is not applicable. Invasion of privacy pertains to disclosing private information about an individual without their consent. Discussing a client's medical condition in a public place such as the hospital cafeteria where others can overhear constitutes an invasion of privacy. The client’s right to confidentiality has been violated, which could lead to a formal complaint. Slander involves spoken statements that are false and damaging to a person's reputation. While the nurses are speaking, there is no indication that what they are saying is false, so slander is not the applicable concern in this situation. Defamation is a broad term that includes both libel and slander, which are false statements made to damage someone's reputation. As mentioned earlier, there is no indication that the statements made by the nurses are false; rather, the issue is the inappropriate sharing of private information.