ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?
- A. Lie on your left side.
- B. Lie on your right side.
- C. Increase your fluid intake.
- D. Decrease your fluid intake.
Correct answer: B
Rationale: After a liver biopsy, the nurse should instruct the client to lie on the right side. This position helps apply pressure to the biopsy site, promoting hemostasis and reducing the risk of bleeding. Lying on the left side may not provide adequate pressure to the site. Increasing fluid intake is generally beneficial to prevent dehydration and aid in the recovery process, whereas decreasing fluid intake could lead to dehydration and possible complications. Therefore, the correct instruction is to lie on the right side.
2. When caring for a patient with hypokalemia, what should the nurse monitor for?
- A. Monitor for muscle weakness
- B. Check for cardiac dysrhythmias
- C. Monitor for bradycardia
- D. Monitor for seizures
Correct answer: A
Rationale: Corrected Answer: Muscle weakness is a common sign of hypokalemia. The nurse should monitor for muscle weakness as potassium plays a crucial role in muscle function. Choices B, C, and D are incorrect because although hypokalemia can lead to cardiac dysrhythmias, bradycardia, and even seizures in severe cases, muscle weakness is a more common and specific sign directly related to potassium levels.
3. A client at high risk for iron deficiency anemia should increase the consumption of which of the following foods?
- A. Yogurt
- B. Apples
- C. Raisins
- D. Cheddar cheese
Correct answer: C
Rationale: The correct answer is C: Raisins. Raisins are a good source of iron, making them beneficial for a client at high risk for iron deficiency anemia. Yogurt (Choice A), apples (Choice B), and cheddar cheese (Choice D) are not significant sources of iron. Other iron-rich foods include dried fruits, red meat, and green leafy vegetables.
4. A patient is receiving discharge instructions for GERD. Which of the following statements by the patient demonstrates an understanding of the teaching?
- A. I should take my medication with orange juice.
- B. Having a bedtime snack will prevent heartburn.
- C. I will lie down after meals.
- D. I will limit activities that require bending at the waist.
Correct answer: D
Rationale: The correct answer is D. Patients with GERD should avoid activities that increase intra-abdominal pressure, such as bending at the waist, as this can lead to reflux. Choice A is incorrect because medications for GERD are usually taken with water, not citrus juices. Choice B is incorrect as having a bedtime snack can worsen GERD symptoms. Choice C is incorrect because lying down after meals can also exacerbate reflux due to the effects of gravity.
5. What are the signs and symptoms of compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized redness and swelling
- C. Fever and infection
- D. Loss of sensation in the affected area
Correct answer: A
Rationale: The signs and symptoms of compartment syndrome include unrelieved pain, pallor, and pulselessness. Unrelieved pain is a key characteristic, indicating tissue ischemia due to increased pressure within a closed anatomic space. Pallor results from compromised blood flow, and pulselessness indicates severe ischemia requiring immediate intervention. Choices B, C, and D are incorrect because localized redness and swelling, fever and infection, and loss of sensation are not specific signs of compartment syndrome. Therefore, the correct answer is A.
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