ATI RN
ATI Nur 175 Med Surg Exam Questions
Extract:
Question 1 of 5
Which of the following is not a common side effect of antidepressant medications?
Correct Answer: D
Rationale: Rashes are not routine side effects of antidepressants.
Question 2 of 5
When planning the delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which element regarding the role of assistive personnel should the nurse consider when delegating tasks?
Correct Answer: B
Rationale: The ability to prioritize is important for the overall management of tasks, but it is not the most critical factor when considering the delegation of specific tasks to assistive personnel. The knowledge and skill to perform the task is crucial when delegating tasks to assistive personnel. Ensuring that the AP has the appropriate training and competence to carry out the task safely and effectively is essential to maintaining high standards of care. Rapport with clients is important for building trust and effective communication, but it is secondary to having the necessary skills and knowledge to perform delegated tasks. While the ability to complete the task without assistance is beneficial, it is more important that the assistive personnel have the required knowledge and skills to perform the task correctly and safely.
Question 3 of 5
A nurse is caring for several clients. For which of the following situations should the nurse complete an incident report?
Correct Answer: A
Rationale: An incident report is necessary when a client discovers that his dentures are missing. This situation involves a loss of personal property and could potentially lead to further complications, such as the client being unable to eat properly or experiencing distress. Documenting the incident ensures proper follow-up and resolution. While identifying a broken piece of equipment is important and should be addressed, it does not typically require an incident report unless the equipment failure has directly caused harm or posed a significant risk to a client or staff member. Reporting the issue through maintenance channels is usually sufficient. A disagreement between the nurse and the nursing supervisor about staffing is an internal issue that should be addressed through appropriate channels such as team meetings or discussions with management, rather than an incident report. A staff member not showing up for their assigned shift is a staffing issue that should be managed through scheduling and human resources processes. It does not typically warrant an incident report unless it directly leads to an adverse event affecting client care.
Question 4 of 5
The nurse calls security and has physical restraints applied to a competent client who becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? (Select All That Apply)
Correct Answer: B,C,E
Rationale:
Choice A reason: Libel refers to written defamation of character. It does not apply to this situation as there are no written statements involved that defame the client.
Choice B reason: Assault involves creating a fear of imminent harmful or offensive contact. In this scenario, the nurse's action of having security apply restraints could be seen as creating an apprehension of physical harm, thereby constituting assault.
Choice C reason: False imprisonment occurs when a person is confined or restrained against their will without legal justification. Applying physical restraints to a competent client who wishes to leave the hospital can be considered false imprisonment.
Choice D reason: Slander refers to spoken defamation of character. Since this situation does not involve spoken statements that defame the client, slander is not applicable.
Choice E reason: Battery involves actual physical contact that is harmful or offensive. Having security apply physical restraints to the client constitutes battery, as it involves unwanted and offensive physical contact.
Question 5 of 5
The nurse is working in the emergency department and is receiving multiple clients from a mass casualty incident. The client arrives by ambulance and is awake, alert, and oriented, complaining of severe abdominal pain with nausea and vomiting. The client's respiratory rate is 20 and has a good radial pulse with normal capillary refill. How would you triage this client using the START triage?
Correct Answer: B
Rationale: The red category in the START triage system is assigned to clients who require immediate life-saving intervention. Although this client is in pain and has severe symptoms, their respiratory rate, pulse, and capillary refill are normal, indicating that they do not need immediate life-saving intervention. The yellow category is designated for clients whose condition is stable but requires observation. This client is awake, alert, and oriented, with a normal respiratory rate, good radial pulse, and normal capillary refill. While they have severe abdominal pain and nausea, their condition does not appear to be life-threatening, making yellow the appropriate triage level. The black category is used 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 they do not fall into this category. The green category is for clients with minor injuries who can walk and do not require urgent medical attention. Since this client has severe symptoms and needs medical attention, the green category is not appropriate.