a patient reports abdominal cramping after enema administration what is the appropriate action

ATI RN

ATI Capstone Medical Surgical Assessment 2 Quizlet

1. A patient reports abdominal cramping after enema administration. What is the appropriate action?

A. Lower the height of the solution container
B. Stop the procedure and remove tubing
C. Increase the flow of enema solution
D. Continue the enema at a slower rate

Correct answer: A

Rationale: Lowering the height of the enema solution container is the appropriate action when a patient reports abdominal cramping after enema administration. This helps reduce the flow rate of the solution, potentially alleviating the cramping. Stopping the procedure and removing tubing (Choice B) would be too abrupt and may not address the issue. Increasing the flow of enema solution (Choice C) could exacerbate the cramping by adding more pressure. Continuing the enema at a slower rate (Choice D) might not provide immediate relief compared to lowering the height of the solution container.

2. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

A. Inspect the pin site every 4 hours
B. Monitor the client's skin under the halo vest
C. Ensure two personnel hold the halo device when repositioning the client
D. Apply powder to the client's skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.

3. What lab value should be monitored in a patient with HIV?

A. CD4 T-cell count below 180 cells/mm3
B. Serum albumin levels
C. Hemoglobin levels
D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it indicates the level of immunocompromise. A CD4 T-cell count below 180 cells/mm3 signifies severe immunosuppression and an increased risk of opportunistic infections. Serum albumin levels (choice B) are important for nutritional status assessment but not specific to HIV monitoring. Hemoglobin levels (choice C) are important for assessing anemia but do not directly reflect HIV disease progression. White blood cell count (choice D) is a general marker of inflammation and infection, but monitoring CD4 T-cell count is more specific and crucial in managing HIV.

4. What precaution should be advised to a patient following a cataract surgery?

A. Wear dark glasses while outdoors
B. Avoid NSAIDs
C. Use warm compresses
D. Apply cold packs

Correct answer: A

Rationale: Following cataract surgery, patients are advised to wear dark glasses while outdoors. This is crucial to protect the eyes from bright light and prevent complications such as excessive glare or discomfort. Choice B, avoiding NSAIDs, is not directly related to post-cataract surgery care. Choices C and D, using warm compresses and applying cold packs, are not typically part of the standard post-operative care for cataract surgery.

5. What is an escharotomy and when is it performed?

A. A surgical incision to release pressure in burn injuries
B. A procedure to remove dead tissue from wounds
C. An incision to improve circulation in tight skin after burns
D. A procedure to remove excess fluid from the chest

Correct answer: A

Rationale: An escharotomy is a surgical incision made to release pressure in a part of the body that has a deep burn and excessive swelling. This procedure is crucial in preventing further damage due to restricted blood flow and compromised circulation. Choice B is incorrect because it describes debridement, which is the removal of dead tissue from wounds. Choice C is incorrect as it does not specifically address the purpose of relieving pressure in burn injuries. Choice D is incorrect as it describes a procedure more related to thoracentesis, which is the removal of excess fluid from the chest, typically the pleural space.