ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. A patient with a chest tube has continuous bubbling in the water seal chamber. What does this indicate?
- A. An air leak
- B. A blocked chest tube
- C. Drainage from the site
- D. Blood clot in the chest tube
Correct answer: A
Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This situation requires immediate attention to prevent complications such as lung collapse. A blocked chest tube would typically result in absent or fluctuating bubbling. Drainage from the site would be observed in the collection chamber, not the water seal chamber. A blood clot in the chest tube would lead to cessation of drainage.
2. A female patient is concerned about the side effects of hormone replacement therapy (HRT). What common side effect should the nurse explain?
- A. Weight gain
- B. Hair loss
- C. Increased libido
- D. Decreased energy levels
Correct answer: A
Rationale: The correct answer is A: Weight gain. Weight gain is a common side effect of hormone replacement therapy (HRT) due to hormonal changes. Patients should be informed about this possibility as part of their treatment plan. Hair loss (Choice B) is not a common side effect of HRT. Increased libido (Choice C) and decreased energy levels (Choice D) are not typically associated with HRT side effects. Therefore, the nurse should focus on discussing weight gain with the patient.
3. A condition that often progresses to become type 2 diabetes mellitus is:
- A. type 1 diabetes mellitus
- B. high blood pressure
- C. chronic pancreatitis
- D. impaired glucose tolerance
Correct answer: D
Rationale: Impaired glucose tolerance is a pre-diabetic state characterized by higher than normal blood sugar levels. It is often associated with insulin resistance and can progress to type 2 diabetes mellitus. Type 1 diabetes mellitus (Choice A) is an autoimmune condition where the body attacks insulin-producing cells, leading to a lack of insulin production. High blood pressure (Choice B) and chronic pancreatitis (Choice C) are not directly linked to the progression to type 2 diabetes mellitus.
4. A client with Hodgkin's disease is receiving Cyclophosphamide IV. Which medication should be administered concurrently to prevent an adverse effect of Cyclophosphamide?
- A. Uroprotectant agent, such as mesna
- B. Opioid, such as morphine
- C. Loop diuretic, such as furosemide
- D. H1 receptor antagonist, such as diphenhydramine
Correct answer: A
Rationale: Mesna, an uroprotectant agent, is administered with nitrogen mustard chemotherapy drugs like Cyclophosphamide to prevent hemorrhagic cystitis, a common adverse effect. Mesna works by binding to and inactivating the toxic metabolites of Cyclophosphamide in the bladder, thereby reducing the risk of bladder toxicity.
5. A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse’s priority?
- A. Administer antibiotics to the client
- B. Increase the client’s protein intake
- C. Teach relaxation breathing to reduce the client’s pain
- D. Provide the client with anti-pyretic therapy
Correct answer: Administer antibiotics to the client
Rationale:
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