ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 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 2 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 3 of 5
During the time-out for a surgical procedure, who is responsible for marking the surgical site?
Correct Answer: C
Rationale: The surgeon marks the site to ensure accuracy and prevent errors.
Question 4 of 5
The nurse is assessing a client with a diagnosis of acute emphysema. The client is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which assessment findings should be reported to the provider immediately?
Correct Answer: B
Rationale: This posture, known as the tripod position, is common among clients with emphysema as it helps them breathe more easily by using accessory muscles. While it indicates respiratory distress, it is not immediately life-threatening. A respiratory rate of 8 breaths/min is significantly below the normal range (12-20 breaths/min) and indicates hypoventilation, which can lead to life-threatening conditions such as hypercapnia (elevated carbon dioxide levels in the blood). This finding needs immediate attention from the provider. A barrel chest is a common physical finding in clients with chronic emphysema. It develops over time due to hyperinflation of the lungs but is not an urgent finding that needs immediate reporting. Fine bibasilar crackles can indicate fluid accumulation in the lungs or other lung pathology, but this finding alone does not necessarily require immediate intervention unless accompanied by other critical symptoms.
Question 5 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.