ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is reviewing the laboratory results for a client who is scheduled for knee arthroplasty later in the day. Which laboratory value is most important to report to the health care provider before the surgery?
Correct Answer: B
Rationale: A hematocrit level of 33.4% is slightly below the normal range, which may indicate mild anemia. While this is important to monitor, it is not as urgent as a high white blood cell count, which could indicate an infection. Mild anemia can typically be managed perioperatively without significant risk. A white blood cell count of 15.5 x10/uL is significantly elevated and suggests an active infection or inflammatory process. Before proceeding with surgery, it is crucial to identify and treat any infections to prevent postoperative complications, such as sepsis. This value is the most critical to report to the healthcare provider to ensure the safety of the surgical procedure. A platelet count of 386,000 mm³ is within the normal range and does not indicate any immediate risk of bleeding or clotting disorders. Thus, this value does not necessitate urgent reporting before surgery. A hemoglobin level of 12.2 g/dL is at the lower end of the normal range, indicating borderline anemia. Although it is important to consider, it does not present as immediate a concern as a potential infection. The surgery can generally proceed with closer monitoring of the client's hemoglobin levels.
Question 2 of 5
A school nurse is helping emergency medical services (EMS) triage students after a bus accident occurred in the school parking lot. A 10-year-old client is awake, alert, and ambulatory but reports a headache and neck pain. Using START triage, what acuity level would be assigned to this client?
Correct Answer: D
Rationale: The red category in START triage is reserved for clients who need immediate intervention to survive. This includes those with life-threatening injuries such as severe bleeding or airway obstruction. In this scenario, the 10-year-old client is awake, alert, and ambulatory, indicating that their condition is not immediately life-threatening.
Therefore, the red category is not applicable. The green category is used for clients who are able to walk and have minor injuries. While the 10-year-old client is ambulatory, the presence of a headache and neck pain suggests that their injuries might be more severe than minor. The green category would not be appropriate because their symptoms indicate a need for further evaluation and monitoring. The black category is assigned to clients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. The 10-year-old client is awake, alert, and able to walk, which clearly does not align with the criteria for the black category.
Therefore, this category is not suitable for the client's condition. The yellow category in START triage is for clients who require medical attention but their injuries are not immediately life-threatening. Given that the 10-year-old client is reporting a headache and neck pain, there is a potential risk of underlying injury that warrants attention but does not require immediate intervention. Thus, the yellow category is the most appropriate acuity level for this client.
Question 3 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 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 newly hired nurse educator for the emergency department is reviewing the hospital disaster plan and policies and finds that it has not been reviewed with the staff for 3 years. Which finding would be most important for the nurse educator to address related to the disaster plan?
Correct Answer: C
Rationale: Depleted stockpiles of medications and resuscitation equipment is a critical concern during a disaster, as it can directly impact the ability to provide care. However, this can typically be addressed by restocking and checking inventory regularly. It is not as immediately crucial as ensuring that all staff are trained and prepared to execute the disaster plan. Changes in hospital resources, such as personnel and infrastructure, can affect the execution of a disaster plan. While this is significant, the most pressing issue is ensuring that the new staff, who may be unfamiliar with the disaster protocols, are adequately trained and ready to respond effectively in an emergency. New staff lacking training and practice in using the disaster plan is the most important finding to address. In a disaster, the ability to implement the plan swiftly and effectively can save lives. Untrained staff may not know their roles, how to use equipment, or the procedures to follow, leading to chaos and ineffective response.
Therefore, it is crucial to ensure all staff are familiar with and have practiced the disaster plan. The risk of technologic disasters in surrounding communities is important to consider in the disaster plan. However, the immediate priority within the hospital is to ensure staff are trained and prepared to handle any disaster scenario. Without proper training, even the best-planned responses to technologic disasters may fail.