ATI RN
ATI Capstone Medical Surgical Assessment 1 Quizlet
1. What should the nurse do for a patient experiencing 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. This action helps relieve the cramping by slowing down the flow of the solution. Choice B, stopping the procedure and removing the tubing, is incorrect as it is too drastic and may not address the cramping. Choice C, continuing the enema at a slower rate, may exacerbate the cramping if the flow rate is still too high. Choice D, increasing the flow of the enema solution, would worsen the cramping and is not the appropriate intervention.
2. What should a healthcare professional do if 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 healthcare professional should lower the height of the enema solution container. This action helps relieve the cramping by slowing down the flow of the enema solution, making it more comfortable for the patient. Stopping the procedure and removing the tubing (Choice B) may be necessary in some cases, but it should not be the first step when cramping occurs. Continuing the enema at a slower rate (Choice C) may exacerbate the cramping, so it is not the best course of action. Increasing the flow of the enema solution (Choice D) will likely worsen the cramping and should be avoided.
3. What intervention is needed when continuous bubbling is observed in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Clamp the chest tube
- C. Replace the chest tube system
- D. Continue monitoring the chest tube
Correct answer: A
Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the correct intervention is to tighten the connections of the chest tube system. This can help resolve an air leak that is causing the continuous bubbling. Clamping the chest tube or replacing the entire chest tube system are not appropriate interventions in this scenario. Clamping the tube can lead to a dangerous buildup of pressure, while replacing the chest tube system may not be necessary if the issue can be resolved by simply tightening the connections. Continuing to monitor the chest tube without taking corrective action may lead to complications associated with the air leak.
4. What is the appropriate electrical intervention for a patient with ventricular tachycardia and a pulse?
- A. Defibrillation
- B. Synchronized cardioversion
- C. Pacing
- D. Medication administration
Correct answer: B
Rationale: Synchronized cardioversion is the correct electrical intervention for a patient with ventricular tachycardia and a pulse. This procedure delivers a synchronized electrical shock to the heart during a specific phase of the cardiac cycle, aiming to restore the heart's normal rhythm. Defibrillation (choice A) is used for pulseless ventricular tachycardia or ventricular fibrillation. Pacing (choice C) is typically used for bradycardias or certain types of heart blocks. Medication administration (choice D) may be used in some cases, but in the scenario of ventricular tachycardia with a pulse, synchronized cardioversion is the preferred intervention.
5. What should a healthcare provider monitor for in a patient with HIV and a CD4 T-cell count below 180 cells/mm3?
- A. Monitor for signs of infection
- B. Monitor for anemia
- C. Monitor for dehydration
- D. Monitor for bleeding
Correct answer: A
Rationale: A CD4 T-cell count below 180 cells/mm3 indicates severe immunocompromise in a patient with HIV. Monitoring for signs of infection is crucial because the patient is at high risk of developing opportunistic infections. Anemia (choice B), dehydration (choice C), and bleeding (choice D) are not directly associated with a low CD4 T-cell count in patients with HIV.
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