ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?
- A. I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league.
- B. I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running.
- C. I'm so upset that this happened to me. What did I do to deserve this?
- D. I feel like I'll never be able to do anything that I want to again. All I am is a burden to my family.
Correct answer: A
Rationale: Choice A is the correct answer because it shows that the client has accepted their disability and is looking towards the future with realistic goals. This positive attitude and focus on engaging in activities that are achievable despite the disability indicate effective coping mechanisms. Choice B is incorrect as it reflects denial of the permanent nature of the disability. Choice C is incorrect as it shows feelings of anger and possible self-blame, which are not indicative of effective coping. Choice D is incorrect as it demonstrates a sense of hopelessness and self-perceived burden, which are signs of maladaptive coping.
2. A nurse is preparing to discharge a client who has a new diagnosis of chronic kidney disease (CKD). Which of the following referrals should the nurse plan to initiate?
- A. Respiratory therapy
- B. Hospice care
- C. Occupational therapy
- D. Dietary services
Correct answer: D
Rationale: The correct answer is D: Dietary services. Referring the client to dietary services is essential for managing nutrition, including monitoring sodium, potassium, and protein intake, which are crucial aspects of managing chronic kidney disease (CKD). Respiratory therapy (choice A) focuses on managing respiratory conditions, which are not directly related to CKD. Hospice care (choice B) is not appropriate for a new diagnosis of CKD as it is designed for end-of-life care. Occupational therapy (choice C) is beneficial for improving activities of daily living but is not the priority referral for a new CKD diagnosis.
3. A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?
- A. Lidocaine
- B. Adenosine
- C. Atropine
- D. Verapamil
Correct answer: C
Rationale: The correct answer is C: Atropine. The client's presentation of bradycardia, diaphoresis, and chest pain indicates reduced cardiac output, requiring intervention to increase the heart rate. Atropine is used to treat bradycardia by blocking cardiac muscarinic receptors, thus inhibiting the parasympathetic nervous system. Lidocaine (Choice A) is used for ventricular arrhythmias, not bradycardia. Adenosine (Choice B) is used for supraventricular tachycardia, not bradycardia. Verapamil (Choice D) is a calcium channel blocker used for certain arrhythmias and hypertension, but not for increasing heart rate in bradycardia.
4. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching?
- A. Immunosuppressant medications need to be taken for up to 1 year
- B. Shortness of breath might be an indication of transplant rejection
- C. The surgical site will heal in 3 to 4 weeks after surgery
- D. Begin 45 minutes of moderate aerobic exercise per day following discharge
Correct answer: B
Rationale: The correct answer is B. Shortness of breath is an important sign of transplant rejection. Other manifestations of rejection include fatigue, edema, bradycardia, and hypotension. Choices A, C, and D are incorrect because: A) Immunosuppressant medications are typically required for life, not just up to 1 year. C) The surgical site healing time can vary and may take longer than 3 to 4 weeks. D) Starting a specific exercise regimen should be individualized and guided by healthcare providers; a general recommendation like 45 minutes of exercise per day may not be suitable for all heart transplant recipients.
5. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?
- A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
- B. Administer oxygen to a client who has an oxygen saturation of 91%
- C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
- D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery
Correct answer: B
Rationale: The priority intervention is administering oxygen. Postoperatively, the client's oxygen saturation should be at or above 95%. Oxygen is essential for tissue perfusion and cellular oxygenation. While managing pain is important, oxygenation takes precedence. Instructing a client about coughing and deep breathing exercises is important for preventing respiratory complications but is not as urgent as addressing low oxygen saturation. Initiating an infusion of 0.9% sodium chloride is a routine postoperative intervention for fluid balance but is not the priority when oxygen saturation is low.
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