ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What should be the first medication given for wheezing due to an allergic reaction?
- A. Albuterol via nebulizer
- B. Cromolyn via nebulizer
- C. Methylprednisolone IV
- D. Aminophylline 500 mg IV
Correct answer: A
Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line medication for treating wheezing caused by an allergic reaction as it works as a bronchodilator, helping to relieve the symptoms of wheezing and shortness of breath quickly. Cromolyn (choice B) is used more for preventing asthma symptoms rather than for immediate relief. Methylprednisolone IV (choice C) and Aminophylline 500 mg IV (choice D) are not the first-line treatments for wheezing due to an allergic reaction.
2. 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.
3. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?
- A. Inspect the pin site every 4 hours
- B. Monitor the client's skin under the halo vest
- C. Ensure two personnel hold the halo device when repositioning the client
- D. Apply powder to the client's skin under the vest to decrease itching
Correct answer: B
Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.
4. 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.
5. What is the primary concern in a patient with a low CD4 T-cell count in HIV?
- A. Increased risk of infection
- B. Increased risk of bleeding
- C. Decreased immunity leading to opportunistic infections
- D. Increased risk of cardiac complications
Correct answer: A
Rationale: The correct answer is A: Increased risk of infection. In HIV patients with a low CD4 T-cell count, the primary concern is the increased susceptibility to infections due to compromised immunity. This compromised immune system can lead to various infections, making infection control crucial. Choice B, increased risk of bleeding, is not directly associated with a low CD4 count in HIV. Option C, decreased immunity leading to opportunistic infections, conveys a similar concern as the correct answer but lacks specificity. Choice D, increased risk of cardiac complications, is not typically the primary concern in HIV patients with a low CD4 count, as infections and opportunistic diseases pose more immediate threats to health.
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