ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is working on the neurological unit. Which task would be most appropriate to delegate to the unlicensed assistive personnel assigned to the unit?
Correct Answer: B
Rationale: Administering tube feedings to a quadriplegic client is a task that typically requires specialized training and knowledge to ensure it is performed safely and correctly. This task is often reserved for licensed nursing personnel due to the potential complications that can arise, such as aspiration or incorrect tube placement.
Therefore, it is not appropriate to delegate this task to unlicensed assistive personnel (UAP). Assisting with bowel training by placing the client on the bedside commode is an appropriate task to delegate to unlicensed assistive personnel. This task involves providing physical assistance and support to the client, which falls within the scope of practice for UAP. It does not require specialized nursing knowledge or skills, making it suitable for delegation. Observing the client demonstrating a self-catheterization technique is a task that requires clinical judgment and assessment skills to ensure the client is performing the procedure correctly and safely. This responsibility is typically within the scope of practice for licensed nurses rather than UAP. Teaching Crede's maneuver to a client needing to void involves providing instruction and education on a specific technique to assist with bladder emptying. This teaching role requires specialized knowledge and skills, making it more appropriate for licensed nursing personnel. It is not suitable for delegation to UAP.
Question 2 of 5
A nurse is caring for a client who is exhibiting a depressed mood one week before the start of their menstrual cycle. The nurse should identify that the client is exhibiting manifestations consistent with which of the following disorders?
Correct Answer: C
Rationale: PMDD causes severe mood disturbances before menstruation.
Question 3 of 5
Which of the following nursing diagnosis take priority immediately after electroconvulsive therapy (ECT)
Correct Answer: D
Rationale: Post-ECT confusion increases injury risk, making safety the priority.
Question 4 of 5
The nurse working in the emergency department is triaging a 65-year-old female client from a mass casualty motor vehicle crash. The client arrives ambulatory by ambulance and is complaining of a headache and neck pain. She is awake, alert, and oriented, and follows commands appropriately. What START triage level would be assigned to this client?
Correct Answer: B
Rationale: The yellow category in the START triage system is for clients who are unable to walk but have stable conditions that do not require immediate life-saving intervention. Since this client is ambulatory, she does not fit into the yellow category. The green category is for clients who are ambulatory with minor injuries and do not require urgent medical attention. This client is awake, alert, oriented, and able to follow commands, indicating that she is stable and her injuries are not life-threatening. The black category 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 stable and responsive, so she does not fit into this category. The red category is for clients who need immediate life-saving intervention. Although this client has a headache and neck pain, her vital signs and ability to follow commands indicate that she does not require immediate life-saving intervention.
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.