ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
The nurse is working on the step-down unit and receives the shift-to-shift report on four clients. Based on the report information, which client would be the highest priority to assess first?
Correct Answer: C
Rationale: A 32-year-old male with a femur fracture in traction is stable but needs ongoing pain management and monitoring for complications like infection or deep vein thrombosis (DVT). While this client requires attention, they are not in immediate critical condition compared to other patients on the list. A 38-year-old female with a grade 1 liver laceration admitted 2 days ago also requires close observation for signs of bleeding or worsening liver function. However, given that the liver laceration is of a lesser severity (grade 1), the immediate priority is less critical compared to a client with respiratory compromise. A 41-year-old male with 4 rib fractures, pneumothorax, and a chest tube is the highest priority. The presence of pneumothorax indicates a potential life-threatening condition that requires close monitoring to ensure the chest tube is functioning correctly and the lung is re-expanding. Any compromise in the chest tube's functionality can lead to respiratory distress or failure, making this client the most critical and requiring immediate assessment. A 55-year-old female admitted 6 days ago with a chest contusion and scheduled for discharge today is likely stable and does not have the same level of urgency as a client with a pneumothorax. This client needs final evaluations and discharge planning, but their condition does not present an immediate life-threatening risk.
Question 2 of 5
The nurse is caring for a group of clients. After making initial rounds, which client is the nurse's priority?
Correct Answer: B
Rationale: This client, although admitted with a bowel obstruction, is currently demonstrating a steady gait while ambulating, suggesting that they are stable at the moment. This client is the priority because they have just received morphine, which requires close monitoring for potential adverse effects, such as respiratory depression. Morphine is a potent opioid, and its administration necessitates vigilant observation to ensure the client's safety. While the client with an infected wound and an elevated white blood cell count and temperature requires attention for infection management, the immediate risk of adverse effects from morphine administration takes precedence. This client, scheduled to begin physical therapy, is stable enough to participate in planned rehabilitation activities, making them a lower priority compared to the client who has just received a potent opioid.
Question 3 of 5
The nurse is educating a transgender female client about the expected outcomes of estrogen therapy. Which statement made by the client would indicate the need for further teaching?
Correct Answer: A
Rationale: This statement is incorrect because estrogen therapy may not effectively reduce the growth of facial hair in transgender women. Additional treatments, such as laser hair removal or electrolysis, may be needed to address facial hair growth. This statement is correct because estrogen therapy can increase the risk of migraine headaches in some individuals. This potential side effect should be discussed with clients considering estrogen therapy. This statement is correct because taking estrogen as prescribed can help decrease muscle mass, which is one of the desired effects of feminizing hormone therapy for transgender women. This statement is correct because estrogen therapy can cause infertility. Transgender women undergoing estrogen therapy should be informed about this potential outcome and consider fertility preservation options if they wish to have biological children in the future.
Question 4 of 5
A nurse receives a shift report on the following clients. Which client should the nurse prioritize first?
Correct Answer: C
Rationale: A client who has undergone a cholecystectomy 2 days ago with decreased bowel sounds might be experiencing a common postoperative issue that requires monitoring but may not need immediate intervention. Decreased bowel sounds can result from the effects of anesthesia, pain medications, or the surgical procedure itself. While this condition warrants attention, it is not as urgent as new-onset confusion in another client. A client with diabetes mellitus and a blood glucose level of 140 mg/dL is within a manageable range, especially in a hospitalized setting. This level of blood glucose does not indicate immediate danger and can be managed with appropriate insulin or oral medication adjustments. It is important for maintaining overall glucose control, but it does not present an urgent situation requiring immediate prioritization over the other clients. A client with a left femur fracture experiencing new-onset confusion is the highest priority. New-onset confusion can be a sign of several serious conditions, such as delirium, infection, or a complication related to the fracture or its treatment. This symptom indicates an acute change in the client's condition that requires immediate assessment and intervention to determine the underlying cause and prevent further complications.
Therefore, this client should be prioritized first. A client admitted for dehydration with a blood pressure of 105/77 mm Hg has a relatively stable blood pressure reading. While dehydration requires prompt treatment with fluids, this client's condition is not as critical as the client experiencing new-onset confusion. The blood pressure reading indicates that the client is maintaining an adequate circulatory status and can be managed after addressing the more urgent needs of the client with confusion.
Question 5 of 5
The nurse has just received a change-of-shift report on the following four clients. Which client should the nurse see first?
Correct Answer: B
Rationale: While the client with a subarachnoid hemorrhage needs close monitoring, the administration of nimodipine is essential but not immediately life-threatening compared to the post-tPA monitoring requirements. This client received tissue plasminogen activator (tP
A) 8 hours ago, which is critical for treating ischemic stroke. They are at a high risk of complications such as bleeding and must be monitored closely for any signs of adverse effects, making them the priority. The client with chronic atrial fibrillation due for warfarin can be attended to after addressing more urgent needs. Chronic atrial fibrillation management is important, but it is less urgent than post-tPA care. The client who experienced a transient ischemic attack and is due for aspirin is stable compared to the client who recently received tPA. While aspirin is important for preventing further strokes, it does not require the same level of immediate monitoring as the post-tPA client.