ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
Which client is at the highest risk for the diagnosis of major depressive disorder?
Correct Answer: D
Rationale: Older, single women are at higher risk due to isolation and health issues.
Question 2 of 5
The nurse provides care to a patient who is mechanically ventilated. Which nursing action is most effective in decreasing the risk for aspiration?
Correct Answer: D
Rationale: Elevating the head of the bed reduces the risk of aspiration by promoting proper alignment and reducing reflux.
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
Which client is at the highest risk for the diagnosis of major depressive disorder?
Correct Answer: D
Rationale: Older, single women are at higher risk due to isolation and health issues.
Question 5 of 5
Which is the priority action by the nurse when a patient discloses a medication allergy during the health history before a surgical procedure?
Correct Answer: C
Rationale: Clarifying the reaction ensures it is a true allergy, guiding appropriate precautions.