ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What are the dietary recommendations for a patient with GERD?
- A. Avoid mint and spicy foods
- B. Eat large meals before bedtime
- C. Consume liquids with meals
- D. Avoid NSAIDs
Correct answer: A
Rationale: The correct answer is to avoid mint and spicy foods for a patient with GERD. These foods can increase gastric acid secretion and worsen symptoms of GERD. Choice B is incorrect because eating large meals before bedtime can exacerbate GERD symptoms due to increased gastric pressure when lying down. Choice C is also incorrect as consuming liquids with meals can lead to increased gastric distention, potentially triggering GERD symptoms. Choice D, avoiding NSAIDs, though important for some patients with GERD due to their potential to irritate the stomach lining, is not a general dietary recommendation for all GERD patients.
2. What is the initial nursing action for a patient with a chest tube found to have an air leak?
- A. Check the tube connections
- B. Replace the chest tube
- C. Remove and reinsert the chest tube
- D. Document the incident
Correct answer: A
Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.
3. A patient reports abdominal cramping during an enema administration. What action should the nurse take?
- A. Increase the flow of the enema
- B. Lower the height of the enema solution container
- C. Stop the enema procedure
- D. Remove the enema tubing
Correct answer: B
Rationale: When a patient experiences abdominal cramping during an enema administration, the nurse should lower the height of the enema solution container. Lowering the container helps to relieve cramping by slowing the flow of the solution, making it more comfortable for the patient. Increasing the flow (Choice A) would exacerbate the cramping. Stopping the procedure (Choice C) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (Choice D) is not the initial action indicated for cramping; adjusting the height is the more appropriate intervention.
4. What is the first nursing action for a patient admitted with chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Check the patient's urine output
- C. Administer IV fluids
- D. Obtain cardiac enzymes
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action for a patient admitted with chest pain from acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. Checking the patient's urine output (Choice B) is not the priority in this situation. Administering IV fluids (Choice C) may not be necessary unless indicated by the patient's condition. Obtaining cardiac enzymes (Choice D) is important but is not the initial action needed to address the patient's acute symptoms.
5. What does continuous bubbling in the chest tube water seal chamber indicate?
- A. An air leak
- B. Normal chest tube function
- C. A blocked chest tube
- D. Continuous drainage from the chest tube
Correct answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system. This occurs when air is entering the system from the outside, preventing the lung from fully re-expanding. Choice B is incorrect because continuous bubbling is not a sign of normal chest tube function. Choice C is incorrect because a blocked chest tube would typically exhibit no bubbling or fluctuation in the water seal chamber. Choice D is incorrect as continuous drainage would not cause bubbling in the water seal chamber.
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