ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration?
- A. Pitting edema of bilateral lower extremities
- B. Hypoactive bowel sounds in all four quadrants
- C. Weight is the same as the day before
- D. Bilateral posterior lung sounds are diminished
Correct answer: A
Rationale: The correct answer is A: Pitting edema of bilateral lower extremities. Pitting edema can indicate fluid overload, which is a potential complication of TPN administration. Choice B, hypoactive bowel sounds, is more indicative of a gastrointestinal issue rather than a complication of TPN. Choice C, weight remaining the same, is expected to remain stable with proper TPN administration. Choice D, diminished lung sounds, is not directly related to TPN administration and is more suggestive of a respiratory issue.
2. What is the learning process aimed at improving health status through changes in knowledge, attitudes, and practices?
- A. Motivating
- B. Counseling
- C. Disease prevention
- D. Health education
Correct answer: D
Rationale: Health education is a structured process that focuses on enhancing health outcomes by modifying individuals' knowledge, attitudes, and behaviors. It aims to empower individuals, families, or communities to make informed decisions and adopt healthy practices, thereby improving overall health status.
3. A nurse in an emergency department is monitoring the hydration status of a client receiving oral rehydration. What finding should the nurse intervene for?
- A. Heart rate of 80 beats per minute
- B. Heart rate of 120 beats per minute
- C. Blood pressure of 110/70 mmHg
- D. Respiratory rate of 16 breaths per minute
Correct answer: B
Rationale: A heart rate of 120 beats per minute indicates tachycardia, which can be a sign of dehydration and requires intervention. A heart rate of 80 beats per minute is within the normal range and does not indicate dehydration. A blood pressure of 110/70 mmHg is considered normal. A respiratory rate of 16 breaths per minute is also within the normal range and does not point towards dehydration.
4. A 7-year-old has been diagnosed with cystic fibrosis. Chest physiotherapy has been ordered. What information should the nurse give to the parents regarding when chest physiotherapy is done?
- A. Before aerosol treatment
- B. After suctioning
- C. Before postural drainage
- D. Before meals
Correct answer: D
Rationale: The correct answer is D: 'Before meals'. Chest physiotherapy should be performed before meals to reduce the risk of vomiting and to ensure that the airways are clear for effective nutrition. Choices A, B, and C are incorrect because chest physiotherapy is ideally done before meals to optimize its benefits and avoid complications associated with timing.
5. Prenatally malnourished babies frequently __________.
- A. reject breast milk
- B. have enlarged hearts
- C. catch respiratory illnesses
- D. have a higher-than-average birth weight
Correct answer: C
Rationale: Prenatally malnourished babies frequently catch respiratory illnesses. Malnourished babies have weakened immune systems, making them more susceptible to illnesses such as respiratory infections. This is a common consequence that is observed in babies who did not receive adequate nutrition during the prenatal period. Choices A, B, and D are incorrect. While malnourished babies may have feeding challenges, rejecting breast milk is not a common consequence. Enlarged hearts are not typically associated with prenatal malnutrition, and having a higher-than-average birth weight is unlikely in malnourished babies.
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