ATI Adult Med Surg RN 3.0: RN Introduction to Critical Care and
Emergency Nursing Assessment Results
Question 1 of 25
A nurse in the emergency department (ED) is triaging a client who is accompanied by an
individual that refuses to leave the client alone with the nurse. While assessing the client, the
nurse notes an unusual tattoo on the client’s inner thigh, as well as multiple bruises near the
groin and lower abdomen. The nurse should consider that the client may need further
evaluation for which of the following?
A. Family counselling
B. A potential infection of the inner thigh
C. Potential human trafficking
D. An association with a club or community group
Answer: C. Potential human trafficking
Question 2 of 25
A newly licensed nurse working in the emergency department(ED) is caring for a client who
has been sexually assaulted. Which of the following reasons is the most frequently cited for
not reporting sexual assaults?
A. Minimizing what happened
B. Fear of retribution
C. Fear of being stigmatized
D. Protecting someone.
Answer: C. Fear of being stigmatized
Question 3 of 25
A nurse is triaging clients in the emergency department using the three-tiered triaging system.
Which of the following clients should the nurse place in the delayed category?
A. A client is admitted with combative and hostile behavior and is screaming that they want
to hurt themselves.
B. A client is reporting a sudden onset of palpitations and anxiety.
Findings indicate a heart rate of 135/min, and blood pressure of 120/70 mm Hg.
C. A client is reporting generalized abdominal pain, nausea, vomiting and diarrhea for 3 days.
Findings indicate that vital signs are stable, and the client has no comorbidities and is taking
no medications.
D. A client is admitted with a temperature of 39 °C(1022.2 °F) and lethargy. The client has
bilateral breast cancer and is currently receiving chemotherapy.
Answer: C. A client is reporting generalized abdominal pain, nausea, vomiting and diarrhea
for 3 days. Findings indicate that vital signs are stable, and the client has no comorbidities
and is taking no medications.
Question 4 of 25
A nurse is preparing to discharge a client who was treated for injuries related to sexual
assault. Which of the following is the most important action for the nurse to take before the
client leaves the facility?
A. Ask the client if they wish to return to their home.
B. Ask the client if they have support at home.
C. Ask the client if they have any questions.
D. Ask the client if they want a follow up appointment with social services.
Answer: C. Ask the client if they have any questions.
Question 5 of 25
A triage nurse is evaluating a client who reports taking anticoagulation medication and
arrived at the emergency department with bleeding from both nares, which slowed after
applying direct pressure to the nose. To which of the following Emergency Severity
Index(ESI) levels should the nurse assign this client?
A. ESI Level 1
B. ESI Level 2
C. ESI Level 3
D. ESI Level 4
Answer: B. ESI Level 2
Question 6 of 25
A nurse is caring for a group of clients in the emergency departments(ED) who were all
exposed to a chemical spill at their job site. A student nurse asks the charge nurse where to
find information about safety regarding the chemical spill. Which of the following responses
by the charge nurse instructs the student to find more information about a chemical spill in
the workplace?
A. “Look up the Safety Data Sheets(SDS) on the hospital Wi-fi network”
B. “Do a web search for the specific chemicals and follow the directions.”
C. “Ask a more experienced coworker that has handled these types of emergencies.”
D. “Ask the supervisor of the workers that were brought to the ED”.
Answer: A. “Look up the Safety Data Sheets(SDS) on the hospital Wi-fi network”
Question 7 of 25
A preceptor in the critical care unit is orienting a newly licensed nurse to the code cart. The
preceptor communicates to the newly licensed nurse that the code carts should be checked at
which of the following intervals?
A. Every 24 hr
B. Every 72 hr
C. Every week
D. Every 2 weeks
Answer: A. Every 24 hr
Question 8 of 25
A newly licensed nurse is providing care to a client admitted to the emergency
department(ED) who is experiencing acute heroin toxicity. The client becomes violent and
strikes the nurse. The nurse speaks with the manager about violence in the ED. Which of the
following statements represents how the nurse manager should respond to the nurse?
A. “clients may fear the possible outcome of their clinical situation, leading to stress”.
B. “The ED is in a violent section of the city.”
C. “The security guards presence heightens the client’s fear of being arrested”.
D. “Families secretly provide illicit drugs to clients while they await treatment”.
Answer: A. “clients may fear the possible outcome of their clinical situation, leading to
stress”.
Question 9 of 25
An emergency department(ED) nurse is reporting on a client who is being transferred to the
intensive care unit(ICU). Which of the following sets of people are responsible for the
transfer report?
A. The ED nurse and the ED provider
B. The ED nurse and the ICU nurse
C. The ED provider and the ED manager
D. The ICU nurse and the ED provider
Answer: B. The ED nurse and the ICU nurse
Question 10 of 25
A nurse is caring for a client admitted to the emergency department(ED) following an injury.
The nurse demonstrates concern and involves the client’s family in the decision making.
Which of the following outcomes is the nurse’s primary goal from this interaction?
A. Ensuring a faster discharge from the ED
B. Creating a trusting relationship.
C. Improving interprofessional communication
D. Documenting client and family interaction
Answer: B. Creating a trusting relationship.
Question 11 of 25
A nurse is caring for a client who has a terminal illness whose life-support equipment is
scheduled to be removed. Which of the following actions should the nurse take first?
A. Clean the client’s room to make it look nice for the family.
B. Prepare in advance how to discuss the situation with the family.
C. Determine what medication should be provided for symptom control during the process of
end of life.
D. Telephone the family as soon as the client’s equipment is removed.
Answer: B. Prepare in advance how to discuss the situation with the family.
Question 12 of 25
A nurse is caring for a client in the emergency department(ED) who reports a history of
myocardial infarction. Which of the following assessment findings is most concering?
A. Chest pain unrelieved by nitroglycerine
B. Blood pressure 148/94 mm Hg
C. Heart rate 100/min
D. Pain in the legs or feet
Answer: A. Chest pain unrelieved by nitroglycerine
Question 13 of 25
A nurse is caring for a client who was admitted to the emergency department (ED) via
ambulance. The client's blood pressure is 110/62 mm Hg, heart rate is 100/min. and
respiratory rate is 28/min. Which of the following represents how the nurse should perform
the "D" portion of the ABCDE assessment?
A. The nurse should check the client's mouth and trachea.
B. The nurse should check for injuries and signs of infection.
C. The nurse should check for central cyanosis and oxygen saturation.
D. The nurse should check alertness and response to voice and pain.
Answer: D. The nurse should check alertness and response to voice and pain.
Question 14 of 25
An emergency department(ED) nurse is preparing for a pandemic disaster situation that
requires more personal protection equipment(PPE) than what is available. Which of the
following elements of resource allocation would be most appropriate for the nurse to
implement?
A. Reusing
B. Conserving
C. Stockpiling
D. Reallocating
Answer: C. Stockpiling
Question 15 of 25
An emergency department (ED) nurse is providing care for a clinet during a chemical disaster
situation. The client is alert and oriented and can walk and follow commands. Which of the
following is the priority action that the nurse should take?
A. Direct the client to the cold or clean zone for immediate treatment.
B. Direct the ED staff to put on protective gear.
C. Take vital signs and perform lung assessment.
D. Direct the client to the decontamination area.
Answer: D. Direct the client to the decontamination area.
Question 16 of 25
A nurse is caring for a client who was admitted to the medical-surgical unit via the
emergency department (ED) 1 week ago following a head injury.Upon further review, the
client was diagnosed with a hip fracture. While the nurse was providing discharge
instructions to the client, the client began to report pai n in the left wrist. Follow-up x-rays
were obtained, and the client was discharged with a cast for a wrist fracture. Which of the
following describes the process performed by the nurse during discharge?
A. The nurse performed a primary survey.
B. The nurse performed a secondary survey.
C. The nurse performed a tertiary survey.
D. The nurse performed the secondary and tertiary surveys.
Answer: C. The nurse performed a tertiary survey.
Question 17 of 25
A nurse is caring for a 30-year-old client who experienced sexual assault 2 days ago. Which
of the following questions is most important to ask the client?
A. "Do we have your permission to contact the police?"
B. "Do you give us permission to take photographs?"
C. "Do you know if you were exposed to HIV?”
D. How did the assault occur?"
Answer: C. "Do you know if you were exposed to HIV?”
Question 18 of 25
A newly licensed nurse working in the emergency department (ED) is learning about the
Emergency Medical Treatment and Active Labor Act (EMTALA). During a current disaster,
the ED is transferring some clients to another facility prior to the clients being stabilized.
Which of the following statements by the nurse manager explains this to the newly licensed
nurse?
A. Clients can be transferred to another facility if they are unstable and require psychiatric
help.
B. A provision of EMTALA permits the transfer of unstable older adults to make room for
minors.
C. Adults may be transferred if unstable, but minors may not be transferred if unstable
D. A provision of EMTALA permits the transfer of clients before they are completely
stabilized.
Answer: B. A provision of EMTALA permits the transfer of unstable older adults to make
room for minors.
Question 19 of 25
A nurse turns off lights in an older adult client's room every night. Which of the following is
the basis for the nurse's intervention?
A. The nurse is implementing this strategy to keep the unit dark.
B. The nurse is implementing this strategy to encourage the client to remain in bed at night
C. The nurse is implementing this strategy to minimize the client's use of the call bell.
D. The nurse is implementing this strategy to prevent the development of delirium In the
client.
Answer: D. The nurse is implementing this strategy to prevent the development of delirium
In the client.
Question 20 of 25
A newly licensed nurse assigned to the critical care unit is caring for a client who requires an
immediate intravenous (IV) access. The nurse does not have the this skill, so they ask a
colleague to insert the IV line. Which of the following questions should the nurse consider?
A. "Where can I find supplies for IV insertion?''
B. "What knowledge can I improve upon?"
C. "Who should I contact to perform IV insertion?"
D. "Where is the policy and procedure regarding IV insertions?"
Answer: B. "What knowledge can I improve upon?"
Question 21 of 25
A nurse is caring for a client who is 1 day postoperative and is currently receiving ventilation.
The nurse is organizing staff to move the client to a chair. The client’s family asks the nurse
why it is necessary to move the client. Which of the following statements best represents how
the nurse should respond?
A. "Clients will need less sedation if they ambulate regularly."
B. "Clients get bored staying in bed and need to participate in what is happening in the unit."
C. "Clients may try to get out of bed themselves, so It is better for us to help them."
D. "Clients must be ambulated as early as possible so they can keep their muscle strength."
Answer: D. "Clients must be ambulated as early as possible so they can keep their muscle
strength."
Question 22 of 25
A nurse is caring for a client in the emergency department(ED) who will most likely not
survive. The client’s family member asks for an update. Which of the following is the best
response by the nurse?
A. Ask the provider to update the family on the status of the client.
B. Refer the family to the charge nurse for information requests.
C. Work with the provider to frequently update the family on the status of the client in a
compassionate way.
D. Provide the family with information once the client has died.
Answer: C. Work with the provider to frequently update the family on the status of the client
in a compassionate way.
Question 23 of 25
Question 24 of 25
Question 25 of 25
