ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. 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.
2. What is the first action when continuous bubbling is observed 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 system
- D. Continue monitoring the chest tube
Correct answer: A
Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the first action should be to tighten the connections of the chest tube system. This step is crucial as it can often resolve an air leak causing continuous bubbling. Clamping the chest tube or replacing the chest tube system would not address the underlying issue of loose connections and may not be necessary. Continuing to monitor the chest tube without taking corrective action may lead to complications if the air leak is not addressed promptly.
3. A nurse is caring for a client who has a new diagnosis of tuberculosis. Which of the following precautions should the nurse initiate to prevent transmission of the disease?
- A. Contact precautions
- B. Airborne precautions
- C. Droplet precautions
- D. Protective environment
Correct answer: B
Rationale: Tuberculosis is spread through small droplets measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client who has TB under airborne precautions to prevent the spread of microbes. Choice A, contact precautions, are used for diseases spread by direct or indirect contact. Choice C, droplet precautions, are for diseases spread by larger droplets. Choice D, protective environment, is used for immunocompromised clients to protect them from environmental pathogens.
4. What should a healthcare professional monitor in a patient receiving insulin who is at risk for hypoglycemia?
- A. Monitor blood glucose levels
- B. Monitor for respiratory distress
- C. Monitor for muscle weakness
- D. Monitor for hyperkalemia
Correct answer: A
Rationale: Monitoring blood glucose levels is crucial in patients receiving insulin who are at risk for hypoglycemia. Insulin can lower blood sugar levels, potentially leading to hypoglycemia, which can be harmful if not promptly recognized and managed. Checking blood glucose levels allows for early detection of low blood sugar levels, enabling timely interventions to prevent complications. Choices B, C, and D are incorrect as they do not directly relate to monitoring for hypoglycemia in patients receiving insulin.
5. What dietary teaching should be provided to a patient with GERD?
- A. Avoid mint and pepper
- B. Consume liquids with meals
- C. Increase fluid intake with meals
- D. Eat large meals before bed
Correct answer: A
Rationale: The correct dietary teaching for a patient with GERD is to avoid mint and pepper. Mint and pepper can trigger reflux symptoms and increase gastric acid secretion, exacerbating GERD. Choices B and C are not recommended for patients with GERD as consuming liquids with meals and increasing fluid intake during meals can contribute to reflux by distending the stomach. Choice D, eating large meals before bed, can also worsen GERD symptoms by increasing pressure on the lower esophageal sphincter and promoting reflux.
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