ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What teaching should be provided to a patient following surgical removal of a cataract?
- A. Avoid NSAIDs
- B. Wear dark glasses while outdoors
- C. Creamy white drainage is normal
- D. Reduce phosphorus intake to 700 mg/day
Correct answer: A
Rationale: The correct teaching to provide to a patient following surgical removal of a cataract is to avoid NSAIDs. NSAIDs can increase the risk of bleeding at the surgical site, so it is important to steer clear of them. Choice B, wearing dark glasses while outdoors, may be recommended post-surgery to protect the eyes from bright light, but it is not the priority teaching in this case. Choice C, stating that creamy white drainage is normal, is not accurate as drainage from the eye should be monitored and reported. Choice D, reducing phosphorus intake to 700 mg/day, is unrelated to post-cataract surgery care and is not a necessary teaching point.
2. A patient is admitted with chest pain, possible acute coronary syndrome. What should the nurse do first?
- A. Administer sublingual nitroglycerin
- B. Get IV access
- C. Obtain cardiac enzymes
- D. Auscultate heart sounds
Correct answer: A
Rationale: In a patient with chest pain, possible acute coronary syndrome, the nurse should administer sublingual nitroglycerin first. Nitroglycerin helps to vasodilate coronary arteries, improving blood flow to the heart, and reducing cardiac workload. This can alleviate chest pain and decrease cardiac tissue damage in acute coronary syndrome. Getting IV access, obtaining cardiac enzymes, and auscultating heart sounds are important steps in the assessment and management of acute coronary syndrome, but administering nitroglycerin to relieve chest pain and improve blood flow takes precedence as it directly addresses the patient's symptoms and aims to prevent further cardiac damage.
3. What dietary instructions should be provided for a patient with pre-dialysis end-stage kidney disease?
- A. Limit phosphorus intake to 700 mg/day
- B. Increase protein intake to 1g/kg/day
- C. Increase sodium intake
- D. Avoid potassium-rich foods
Correct answer: A
Rationale: Patients with pre-dialysis end-stage kidney disease should limit phosphorus intake to manage their condition. Excessive phosphorus can lead to mineral and bone disorders in patients with kidney disease. Choices B, C, and D are incorrect. Increasing protein intake is not recommended as it can burden the kidneys. Increasing sodium intake is usually discouraged due to its association with hypertension and fluid retention in kidney disease. Avoiding potassium-rich foods is more relevant in advanced kidney disease stages when potassium levels are high, not in pre-dialysis end-stage kidney disease.
4. What teaching should be provided to a patient after cataract surgery?
- A. Avoid NSAIDs
- B. Avoid bright lights
- C. Wear dark glasses while outdoors
- D. Use warm compresses
Correct answer: A
Rationale: The correct teaching to provide to a patient after cataract surgery is to avoid NSAIDs. NSAIDs should be avoided to reduce the risk of bleeding post-surgery. Choices B, C, and D are not directly related to post-cataract surgery care. Avoiding bright lights and wearing dark glasses while outdoors may be beneficial for eye comfort but are not specific postoperative instructions. Using warm compresses is also not a standard teaching after cataract surgery.
5. What should be the priority action when a patient is admitted with chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Obtain IV access
- C. Check cardiac enzymes
- D. Administer aspirin
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action in treating chest pain associated with acute coronary syndrome as it helps to dilate blood vessels, improve blood flow to the heart, and reduce cardiac tissue damage. Administering nitroglycerin is crucial in managing the symptoms and potential complications of acute coronary syndrome. Obtaining IV access (Choice B) is important for administering medications and fluids but does not address the immediate symptom of chest pain. Checking cardiac enzymes (Choice C) and administering aspirin (Choice D) are essential steps in the management of acute coronary syndrome, but they should follow the administration of nitroglycerin to address the immediate symptom and improve blood flow to the heart.
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