ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What dietary recommendations should be provided to a patient with GERD?
- A. Avoid mint and spicy foods
- B. Eat large meals before bed
- C. Consume liquids with meals
- D. Avoid foods high in potassium
Correct answer: A
Rationale: The correct recommendation for a patient with GERD is to avoid mint and spicy foods. These types of foods can trigger acid reflux and worsen GERD symptoms. Choice B is incorrect as eating large meals before bed can increase the likelihood of acid reflux due to increased pressure on the lower esophageal sphincter. Choice C is also incorrect as consuming liquids with meals can cause distension in the stomach, potentially leading to reflux. Choice D is not directly related to GERD, as foods high in potassium are generally healthy and not specifically problematic for GERD patients.
2. What is the priority nursing intervention for a patient admitted with possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Obtain cardiac enzymes
- C. Get IV access
- D. Auscultate heart sounds
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This intervention is a priority for a patient with possible acute coronary syndrome because nitroglycerin helps vasodilate coronary arteries, increase blood flow to the heart muscle, relieve chest pain, and reduce cardiac workload. Obtaining cardiac enzymes (choice B) is important for diagnosing myocardial infarction but is not the initial priority. Getting IV access (choice C) is essential for medication administration and fluid resuscitation but is not the priority over administering nitroglycerin. Auscultating heart sounds (choice D) is a routine assessment but does not address the immediate need to relieve chest pain and improve blood flow to the heart in acute coronary syndrome.
3. What ECG changes are seen in hypokalemia?
- A. Flattened T waves on the ECG
- B. Elevated ST segments on the ECG
- C. Widened QRS complex
- D. Prominent U waves on the ECG
Correct answer: A
Rationale: The correct answer is A: Flattened T waves on the ECG. Flattened T waves are an early indicator of hypokalemia on an ECG. Choice B, Elevated ST segments, is not typically seen in hypokalemia but can be a sign of myocardial infarction. Choice C, Widened QRS complex, is more commonly associated with hyperkalemia. Choice D, Prominent U waves, is typically associated with hypokalemia, but flattened T waves are considered a more specific and early sign.
4. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?
- A. Keep a padded tongue depressor near the bedside
- B. Place a pillow under the client's head during a seizure
- C. Administer diazepam intravenously at the onset of seizures
- D. Position the client on their side during a seizure
Correct answer: D
Rationale: The correct intervention for a client who has a seizure disorder is to position the client on their side during a seizure. This helps to prevent aspiration and ensures a patent airway. Keeping a padded tongue depressor near the bedside (Choice A) is not recommended as it can cause injury during a seizure. Placing a pillow under the client's head during a seizure (Choice B) is also not advised as it can obstruct the airway. Administering diazepam intravenously at the onset of seizures (Choice C) is not typically done at home without healthcare provider direction.
5. 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.
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