ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What precaution should be advised to patients following cataract surgery?
- A. Wear dark glasses while outdoors
- B. Use warm compresses
- C. Avoid NSAIDs
- D. Avoid bright lights
Correct answer: A
Rationale: Patients who have undergone cataract surgery should wear dark glasses when outdoors to shield their eyes from light exposure, which can be uncomfortable or harmful during the recovery period. Using warm compresses (choice B) is not typically recommended after cataract surgery as it's more relevant for certain eye conditions. Avoiding NSAIDs (choice C) is advised to prevent bleeding complications, but it is not directly related to eye protection post-surgery. While avoiding bright lights (choice D) is crucial, wearing dark glasses provides a practical solution to achieve this, making choice A the most appropriate precaution.
2. What are the signs and symptoms of a hemorrhagic stroke?
- A. Sudden severe headache, decreased level of consciousness, and seizures
- B. Loss of consciousness and weakness
- C. Temporary vision loss
- D. Severe chest pain and shortness of breath
Correct answer: A
Rationale: The correct answer is A. A hemorrhagic stroke often presents with a sudden severe headache, decreased level of consciousness, and seizures due to bleeding in the brain. Choice B, loss of consciousness and weakness, is more indicative of an ischemic stroke where a clot blocks blood flow to the brain. Choice C, temporary vision loss, is more commonly seen in conditions like transient ischemic attacks (TIAs) or retinal migraines. Choice D, severe chest pain and shortness of breath, are symptoms more associated with cardiac issues like a heart attack.
3. What is the priority action if a patient experiences abdominal cramping during enema administration?
- A. Lower the height of the solution container
- B. Increase the flow of the enema solution
- C. Stop the procedure and remove the tubing
- D. Continue the enema at a slower rate
Correct answer: A
Rationale: During enema administration, if a patient experiences abdominal cramping, the priority action is to lower the height of the solution container. This adjustment can help relieve abdominal cramping by reducing the flow rate of the enema, making it more comfortable for the patient. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in some cases of severe discomfort or complications, but adjusting the height of the solution container should be the initial response. Continuing the enema at a slower rate (Choice D) may not address the immediate need to alleviate the cramping.
4. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?
- A. Axillary temperature 37.2°C (99°F)
- B. Apical pulse 100/min
- C. Respiratory rate 30/min
- D. Blood pressure 140/84 mm Hg
Correct answer: C
Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.
5. What intervention should the nurse take for a patient experiencing delayed wound healing?
- A. Monitor serum albumin levels
- B. Apply a dry dressing
- C. Administer antibiotics
- D. Change the wound dressing every 8 hours
Correct answer: A
Rationale: Monitoring serum albumin levels is crucial for patients with delayed wound healing. Low albumin levels indicate a lack of protein, which can impair the healing process and increase the risk of infection. By monitoring serum albumin levels, the nurse can assess the patient's nutritional status and make necessary interventions to promote wound healing. Applying a dry dressing (Choice B) may be appropriate depending on the wound characteristics, but it does not address the underlying cause of delayed healing. Administering antibiotics (Choice C) is not the first-line intervention for delayed wound healing unless there is an active infection present. Changing the wound dressing every 8 hours (Choice D) may lead to excessive disruption of the wound bed and hinder the healing process.
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