ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What should the nurse do when a patient experiences abdominal cramping during enema administration?
- A. Lower the height of the enema solution container
- B. Stop the procedure and remove the tubing
- C. Continue the enema at a slower rate
- D. Increase the flow of the enema solution
Correct answer: A
Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. Lowering the height helps relieve cramping by slowing down the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is incorrect as it does not directly address the cramping issue. Choice C, continuing the enema at a slower rate, could potentially worsen the cramping by prolonging the discomfort. Choice D, increasing the flow of the enema solution, is also incorrect as it may intensify the cramping and cause more discomfort to the patient.
2. What should be taught to a patient following cataract surgery?
- A. Avoid NSAIDs
- B. Wear dark glasses when outdoors
- C. Report green or yellow drainage immediately
- D. Itching is normal unless accompanied by pain and nausea
Correct answer: A
Rationale: The correct answer is to avoid NSAIDs after cataract surgery to reduce the risk of bleeding. Choice B, wearing dark glasses when outdoors, is generally recommended after cataract surgery to protect the eyes from bright sunlight, but it is not the most critical instruction. Choice C, reporting green or yellow drainage immediately, is important to monitor for signs of infection, but it is not specific to cataract surgery. Choice D, itching is normal unless accompanied by pain and nausea, is not the most crucial advice post-cataract surgery. Therefore, the key instruction is to avoid NSAIDs to minimize bleeding risk.
3. What is the priority dietary modification for a patient with pre-dialysis end-stage kidney disease?
- A. Limit phosphorus intake to 700 mg/day
- B. Increase potassium intake to 3 g/day
- C. Eat three large meals per day
- D. Restrict protein intake to 1 g/kg/day
Correct answer: A
Rationale: The correct answer is A: Limit phosphorus intake to 700 mg/day. In patients with pre-dialysis end-stage kidney disease, restricting phosphorus intake is crucial to manage their condition. Excessive phosphorus can lead to mineral and bone disorders, which are common in kidney disease. Choice B, increasing potassium intake, is not the priority and can be harmful as kidney disease often leads to hyperkalemia. Choice C, eating three large meals per day, is not recommended as smaller, frequent meals are usually better tolerated. Choice D, restricting protein intake to 1 g/kg/day, is important in later stages of kidney disease but is not the priority at the pre-dialysis stage.
4. A patient with ventricular tachycardia and a pulse needs electrical intervention. What is the appropriate action?
- A. Defibrillation
- B. Synchronized cardioversion
- C. Pacing
- D. Medication administration
Correct answer: B
Rationale: For a patient with ventricular tachycardia and a pulse, the appropriate action is synchronized cardioversion. Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Pacing is typically used for bradycardias. Medication administration may be considered in stable ventricular tachycardia cases but electrical intervention is preferred for immediate correction in this scenario.
5. What should a healthcare professional monitor for in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized redness and swelling
- C. Fever and signs of infection
- D. Loss of deep tendon reflexes
Correct answer: A
Rationale: Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome. In this condition, increased pressure within a muscle compartment impairs blood flow, leading to severe pain that is not relieved by usual measures, pallor from decreased blood flow, and pulselessness due to compromised circulation. These signs indicate a medical emergency requiring immediate intervention. Localized redness and swelling (Choice B) are more characteristic of inflammation or infection rather than compartment syndrome. Fever and signs of infection (Choice C) are not typical manifestations of compartment syndrome. Loss of deep tendon reflexes (Choice D) is associated with conditions affecting the nervous system, not compartment syndrome.
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