ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. When providing discharge teaching to a patient who underwent cataract surgery, what should the patient avoid?
- A. Avoid NSAIDs
- B. Avoid bright lights
- C. Avoid alcohol
- D. Avoid phosphorus-rich foods
Correct answer: A
Rationale: The correct answer is to avoid NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding after cataract surgery due to their anticoagulant properties. Bright lights (choice B) are not contraindicated post-cataract surgery unless the patient experiences discomfort or sensitivity. Alcohol consumption (choice C) is generally not restricted after cataract surgery, but moderation is recommended. Phosphorus-rich foods (choice D) are not directly related to cataract surgery postoperative care.
2. 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.
3. A client has a right-sided pneumothorax, and a chest tube is inserted. Which finding indicates that the chest drainage system is functioning correctly?
- A. Gentle bubbling in the suction chamber
- B. Crepitus around the insertion site
- C. Constant bubbling in the water seal chamber
- D. Absence of breath sounds on the right side
Correct answer: A
Rationale: In a chest drainage system, gentle bubbling in the suction chamber indicates proper functioning, showing that the system is connected and working effectively to remove air or fluid from the pleural space. Crepitus around the insertion site (Choice B) suggests subcutaneous emphysema, not chest tube functionality. Constant bubbling in the water seal chamber (Choice C) indicates an air leak. Absence of breath sounds on the right side (Choice D) is indicative of the pneumothorax, not the chest tube function.
4. What are the expected findings in a patient with hypokalemia?
- A. Cardiac dysrhythmias
- B. Seizures and confusion
- C. Bradycardia
- D. Muscle weakness
Correct answer: A
Rationale: The correct answer is A: Cardiac dysrhythmias. Hypokalemia is commonly associated with cardiac dysrhythmias due to the role potassium plays in maintaining proper electrical conduction in the heart. Choices B, C, and D are incorrect. While hypokalemia can lead to muscle weakness, the most critical and life-threatening manifestation is cardiac dysrhythmias. Seizures and confusion are more commonly associated with other electrolyte imbalances, such as hyponatremia. Bradycardia is not a typical finding in hypokalemia, as it tends to cause tachycardia or other arrhythmias.
5. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?
- A. 1 packet of reconstituted dry onion soup
- B. 3 oz of lean cured ham
- C. 3 oz of chicken breast
- D. ½ cup of canned baked beans
Correct answer: C
Rationale: For a client with hypertension, a low sodium diet is recommended to help control blood pressure. Among the food choices provided, the best option is 3 oz of chicken breast. Chicken breast is lean protein with lower sodium content compared to other choices. It is a healthier option for managing hypertension. Reconstituted dry onion soup (Choice A) and canned baked beans (Choice D) typically contain higher amounts of sodium, which can be detrimental for blood pressure management. Lean cured ham (Choice B) also tends to have a higher sodium content, making it less suitable for a client with hypertension.
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