ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What ECG changes are seen with hyperkalemia?
- A. Flattened T waves
- B. Elevated ST segments
- C. Prominent U waves
- D. Widened QRS complex
Correct answer: A
Rationale: Flattened T waves are an early ECG sign of hyperkalemia. Hyperkalemia affects the repolarization phase of the cardiac action potential, leading to changes such as peaked T waves, prolonged PR interval, widened QRS complex, and ultimately sine wave pattern. Elevated ST segments, prominent U waves, and widened QRS complex are not typically associated with hyperkalemia, making choices B, C, and D incorrect.
2. What is the correct response when a patient receiving an enema reports abdominal cramping?
- A. Lower the height of the enema container
- B. Stop the enema procedure
- C. Remove the enema tubing
- D. Continue the enema at a slower rate
Correct answer: A
Rationale: The correct response when a patient receiving an enema reports abdominal cramping is to lower the height of the enema container. Lowering the height reduces the flow rate, which can help relieve cramping. Stopping the procedure (choice B) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (choice C) is not the initial step to take when addressing abdominal cramping during an enema. Continuing the enema at a slower rate (choice D) might not be as effective as lowering the height of the container to alleviate cramping.
3. What should the nurse do when continuous bubbling is seen in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Clamp the chest tube
- C. Replace 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 nurse should tighten the connections of the chest tube system. This action can often resolve an air leak causing the continuous bubbling. Clamping the chest tube or replacing it would not address the underlying issue of an air leak and may lead to complications. Continuing to monitor the chest tube without taking corrective action may result in the deterioration of the patient's condition.
4. A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend?
- A. Low potassium diet
- B. High fiber diet
- C. Low fat diet
- D. Low sodium diet
Correct answer: C
Rationale: The correct answer is C: Low fat diet. A low-fat diet is recommended for clients with chronic cholecystitis to reduce episodes of biliary colic. High-fat foods can trigger symptoms by causing the gallbladder to contract, leading to pain. Choice A, a low potassium diet, is not specifically indicated for chronic cholecystitis. Choice B, a high fiber diet, though generally healthy, may worsen symptoms in some individuals with cholecystitis due to the increased intestinal gas production. Choice D, a low sodium diet, is not directly related to the management of chronic cholecystitis.
5. What is the priority intervention for a patient with unstable angina?
- A. Administer nitroglycerin
- B. Establish IV access
- C. Auscultate heart sounds
- D. Administer aspirin
Correct answer: A
Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with unstable angina as it helps dilate blood vessels, improve blood flow to the heart, relieve chest pain, and prevent further cardiac damage. Establishing IV access (choice B) may be important but is not the priority over administering nitroglycerin in this scenario. Auscultating heart sounds (choice C) and administering aspirin (choice D) are also important aspects of managing unstable angina, but they are not the immediate priority intervention when a patient is experiencing chest pain.
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