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. 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. What intervention should be done if continuous bubbling is seen in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Replace the chest tube system
- C. Clamp the chest tube
- D. Continue monitoring the chest tube
Correct answer: A
Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the appropriate intervention is to tighten the connections of the chest tube system. This step helps address an air leak in the system, which could compromise its effectiveness. Choice B (Replace the chest tube system) is not the initial step and may be unnecessary if the issue can be resolved by tightening connections. Choice C (Clamp the chest tube) is incorrect as clamping the chest tube could lead to a dangerous increase in pressure within the system. Choice D (Continue monitoring the chest tube) is also not the best immediate action to take when continuous bubbling is present, as prompt intervention is needed to prevent complications.
4. What are the expected manifestations of a thrombotic stroke?
- A. Gradual loss of function on one side of the body
- B. Loss of sensation in the affected extremity
- C. Sudden loss of consciousness
- D. Seizures and convulsions
Correct answer: A
Rationale: The correct answer is A: Gradual loss of function on one side of the body. Thrombotic strokes are caused by a clot forming in a blood vessel supplying the brain, leading to a gradual onset of symptoms due to impaired blood flow to specific brain regions. Choices B, C, and D are incorrect because loss of sensation, sudden loss of consciousness, seizures, and convulsions are not typically associated with thrombotic strokes. In a thrombotic stroke, the symptoms develop slowly over time, often over minutes to hours, and include manifestations such as weakness, numbness, or paralysis on one side of the body, along with other symptoms related to the affected brain area.
5. What action should a healthcare provider take if a patient reports cramping during enema administration?
- A. Lower the height of the solution container
- B. Increase the flow of the enema solution
- C. Stop the procedure and remove the tubing
- D. Continue the enema at a slower rate
Correct answer: A
Rationale: When a patient reports cramping during enema administration, the best action is to lower the height of the enema solution container. This adjustment helps relieve abdominal cramping by slowing down the flow of the enema, making it more comfortable for the patient. Increasing the flow of the solution (choice B) would exacerbate the cramping. Stopping the procedure and removing the tubing (choice C) may be necessary in some cases but should not be the first response to cramping. Continuing the enema at a slower rate (choice D) might not be as effective as lowering the height of the solution container in addressing the cramping.
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