ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO2 29 mm Hg, and HCO3- 25 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct answer: B
Rationale: The correct answer is B: Respiratory alkalosis. In this scenario, the client is experiencing respiratory alkalosis due to hyperventilation. Hyperventilation leads to excessive loss of carbon dioxide, causing a decrease in hydrogen ion concentration and an increase in pH levels. Choices A, C, and D are incorrect. Respiratory acidosis is characterized by high PaCO2 and low pH. Metabolic acidosis is associated with low HCO3- levels and low pH. Metabolic alkalosis is marked by high HCO3- levels and high pH. In this case, the ABG results indicate respiratory alkalosis.
2. A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the following should the nurse include as a risk factor for osteoporosis?
- A. Early menopause
- B. History of falls
- C. African American race
- D. Obesity
Correct answer: A
Rationale: The correct answer is A: Early menopause. A client who goes into early menopause, from natural or surgical causes, is at a greater risk for developing osteoporosis due to the rapid drop in estrogen levels. Choice B, history of falls, is not a direct risk factor for osteoporosis but rather a risk for fractures related to osteoporosis. Choice C, African American race, is actually associated with a lower risk of osteoporosis. Choice D, obesity, is considered a protective factor against osteoporosis as excess weight can provide additional support to bones.
3. A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend?
- A. Low potassium diet
- B. High fiber diet
- C. Low fat diet
- D. Low sodium diet
Correct answer: C
Rationale: The correct answer is C: Low fat diet. A low-fat diet is recommended for clients with chronic cholecystitis to reduce episodes of biliary colic. High-fat foods can trigger symptoms by causing the gallbladder to contract, leading to pain. Choice A, a low potassium diet, is not specifically indicated for chronic cholecystitis. Choice B, a high fiber diet, though generally healthy, may worsen symptoms in some individuals with cholecystitis due to the increased intestinal gas production. Choice D, a low sodium diet, is not directly related to the management of chronic cholecystitis.
4. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?
- A. Axillary temperature 37.2°C (99°F)
- B. Apical pulse 100/min
- C. Respiratory rate 30/min
- D. Blood pressure 140/84 mm Hg
Correct answer: C
Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.
5. A client is scheduled for an electroencephalogram (EEG) and a nurse is providing teaching. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should not wash my hair prior to the procedure.
- B. I will receive a sedative 1 hour before the procedure.
- C. I should avoid eating prior to the procedure.
- D. I will be exposed to flashes of light during the procedure.
Correct answer: D
Rationale: The correct answer is D. The nurse should inform the client that flashes of light or pictures are often used during the procedure to assess the brain's response to stimuli. Choices A, B, and C are incorrect because washing hair, receiving a sedative, and avoiding eating are not directly related to the EEG procedure.
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