ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. 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.
2. The nurse is caring for a very low-birth-weight (VLBW) infant with a peripheral intravenous infusion. What nursing considerations regarding infiltration should be included in planning IV care?
- A. Infiltration is not solely related to the activity level of VLBW infants.
- B. Continuous infusion pumps do not always stop automatically when infiltration occurs.
- C. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
- D. The infusion site should be checked regularly to prevent infiltration-related complications.
Correct answer: C
Rationale: Hypertonic solutions can damage tissues if they leak from the vein due to infiltration. It is crucial to monitor for this complication to prevent severe tissue damage. Infiltration is not solely related to the activity level of VLBW infants; it can occur due to various reasons such as vein condition, catheter placement, and fluid type. Continuous infusion pumps may not always detect infiltration, as they typically alarm for pressure changes but not all infiltration instances. Checking the infusion site regularly, preferably hourly, is essential to prevent complications like tissue damage from extravasations, fluid overload, and dehydration.
3. What is the most appropriate action for a child with epistaxis?
- A. Have the child lie flat
- B. Pinch the nose and lean forward
- C. Apply a warm compress to the nose
- D. Encourage deep breathing
Correct answer: B
Rationale: The most appropriate action for a child with epistaxis is to pinch the nose and lean forward. This technique helps stop the bleeding and prevent aspiration of blood. By applying pressure to the bleeding vessels and allowing the blood to drain out of the nostrils instead of being swallowed, the risk of nausea and airway obstruction is reduced. Having the child lie flat (Choice A) may lead to blood flowing down the throat, causing potential choking. Applying a warm compress (Choice C) is not typically recommended for epistaxis as cold compresses are more effective. Encouraging deep breathing (Choice D) is not directly related to managing epistaxis.
4. The client is on spironolactone (Aldactone). What is the most important dietary instruction?
- A. Avoid foods high in potassium.
- B. Increase intake of foods high in potassium.
- C. Avoid foods high in sodium.
- D. Increase intake of foods high in sodium.
Correct answer: A
Rationale: The correct answer is to avoid foods high in potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium and can lead to hyperkalemia if too much potassium is consumed. Choices B, C, and D are incorrect because increasing intake of potassium-rich foods can worsen hyperkalemia, while avoiding foods high in sodium is not the primary concern when taking spironolactone.
5. A client with asthma is being taught about peak flow meter use. Which statement by the client indicates understanding of the teaching?
- A. I will use my peak flow meter every morning.
- B. I will use my peak flow meter when I feel short of breath.
- C. I will use my peak flow meter before using my inhaler.
- D. I will use my peak flow meter after using my inhaler.
Correct answer: A
Rationale: The correct answer is A. Using the peak flow meter every morning is crucial for monitoring asthma control and making timely treatment adjustments. While using the meter when feeling short of breath or before using an inhaler can also be beneficial, the daily morning routine helps in consistent management of asthma symptoms.
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