a nurse in an emergency department is performing triage for multiple clients following a disaster in the community to which of the following types of a nurse in an emergency department is performing triage for multiple clients following a disaster in the community to which of the following types of
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ATI Exit Exam 180 Questions Quizlet

1. In an emergency department following a community disaster, a healthcare provider is performing triage for multiple clients. To which of the following types of injuries should the provider assign the highest priority?

Correct answer: A

Rationale: During disaster triage, clients with severe injuries that are immediately life-threatening and have a high likelihood of mortality without intervention are assigned the highest priority. A below-the-knee amputation falls into this category as it indicates a critical injury that requires immediate attention to prevent further complications or loss of life. Fractured tibia, a 95% full-thickness body burn, and a 10 cm laceration to the forearm, while serious, do not pose the same level of immediate life-threatening risk as a below-the-knee amputation in the context of disaster triage.

2. Development is best understood as __________.

Correct answer: D

Rationale: The correct answer is D. Development is best understood as a series of complex exchanges between nature (genetic factors) and nurture (environmental influences). This perspective emphasizes the interaction and interplay between genetic predispositions and environmental experiences in shaping an individual's development. Choices A and B are too extreme as they suggest that development is solely determined by genetics or solely influenced by the environment, which is not the case. Choice C is incorrect as development is not viewed as an unsolvable puzzle but rather as a dynamic process influenced by multiple factors.

3. Third spacing occurs when fluid moves out of the intravascular space but not into the intracellular space. Based on this fluid shift, the nurse will expect the patient to demonstrate:

Correct answer: D

Rationale: In the scenario of third-spacing fluid shift, where fluid moves out of the intravascular space but not into the intracellular space, the patient is expected to demonstrate hypovolemia. Hypertension (Choice A) is unlikely as hypovolemia typically leads to decreased blood pressure. Bradycardia (Choice B) is not a common manifestation of hypovolemia, as the body often tries to compensate by increasing heart rate. Hypervolemia (Choice C) indicates an excess of fluid, which is the opposite of what occurs in third spacing.

4. A nurse is caring for a client who reports a decrease in the effectiveness of their pain medication. What factor should the nurse identify as contributing to this decrease?

Correct answer: C

Rationale: The correct answer is C: Bowel inflammation. Bowel inflammation can interfere with the absorption of medications, including pain medication, leading to decreased effectiveness. Choices A, B, and D are incorrect because although they can impact pain management in various ways, they are not directly related to the decreased effectiveness of pain medication due to absorption issues.

5. A client has a new prescription for Spironolactone. Which of the following instructions should be provided?

Correct answer: B

Rationale: The correct answer is to 'Avoid potassium-rich foods.' Spironolactone is a potassium-sparing diuretic, and consuming foods high in potassium can lead to hyperkalemia, a potential side effect of the medication. Therefore, the client should be advised to avoid potassium-rich foods to prevent complications. Choices A, C, and D are incorrect. Taking Spironolactone with food is not necessary for its effectiveness. Increasing sodium intake is not typically recommended with Spironolactone therapy. While monitoring blood pressure is important, it is not specifically related to the use of Spironolactone.

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