ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 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 2 of 5
Which of the following is a characteristic of tardive dyskinesia?
Correct Answer: B
Rationale: Tardive dyskinesia involves repetitive, involuntary movements.
Question 3 of 5
The nurse supervisor is working in a hospital that is in the path of a hurricane. Which of the following clients would be appropriate for immediate discharge?
Correct Answer: D
Rationale: A client with lymphoma receiving inpatient chemotherapy is likely to require close monitoring and ongoing treatment due to the potential complications associated with their condition and treatment. Discharging this client could put them at significant risk. A client with heart failure with crackles bilaterally on 4 liters of oxygen needs continuous medical supervision and care to manage their heart condition and oxygen levels. Discharging this client could exacerbate their heart failure and lead to serious health complications. A client who is post-appendectomy with a paralytic ileus is at risk of complications such as bowel obstruction and infection. They need to be closely monitored in the hospital until their condition stabilizes and they begin to recover from surgery. A client with a nondisplaced tibia fracture that has been immobilized is generally stable and can be safely discharged with appropriate instructions for home care. This client does not require intensive monitoring and can continue their recovery at home.
Question 4 of 5
An experienced charge nurse is providing mentoring to a new charge nurse. The new charge nurse is making the shift assignment for a licensed practical nurse (LPN). Which assignment requires intervention by the experienced nurse?
Correct Answer: C
Rationale: Providing nasopharyngeal suctioning for a client with pneumonia is within the scope of practice for an LPN. This task involves performing a procedure to clear the airway, which is a common responsibility for LPNs. Assisting a client who is 24 hours post-operative to use an incentive spirometer is appropriate for an LPN. This task involves helping a client with breathing exercises to prevent post-operative complications, which is a standard part of post-operative care. Teaching a new client who has asthma to use a metered-dose inhaler requires educational and assessment skills that typically fall within the scope of practice for a registered nurse (RN). While LPNs can reinforce education, the initial teaching and assessment of a client's understanding should be done by an RN. Collecting a clean catch urine from an ambulatory client with a wound is within the scope of practice for an LPN. This task involves obtaining a urine sample, which is a routine procedure that LPNs are trained to perform.
Question 5 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.