ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. 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.
2. After surgery, your patient starts to shiver uncontrollably. What nursing intervention would you do first?
- A. Apply warm blankets & continue oxygen as prescribed
- B. Take the patient's rectal temperature
- C. Page the doctor for further orders
- D. Adjust the thermostat in the room
Correct answer: Apply warm blankets & continue oxygen as prescribed
Rationale: When a patient starts shivering uncontrollably after surgery, the priority nursing intervention is to apply warm blankets and continue oxygen as prescribed. Shivering can be a sign of hypothermia, and maintaining the patient's body temperature is crucial for their recovery. This intervention helps prevent further heat loss and supports the patient's comfort and safety. While monitoring temperature, paging the doctor, and adjusting the room temperature may be necessary, addressing the immediate need for warmth and oxygen is the priority in this situation.
3. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?
- A. . Apply oxygen by mask or nasal cannula
- B. Apply a paper bag over the clients nose and mouth.
- C. Administer 50 mL of sodium bicarbonate intravenously.
- D. Administer 50 mL of 20% glucose and 20 units of regular insulin.
Correct answer: . Apply oxygen by mask or nasal cannula
Rationale:
4. A client with multiple sclerosis (MS) is frustrated by tremors associated with the disease. How should the nurse explain why these tremors occur? Due to the demyelination of neurons that occurs in MS:
- A. there is an imbalance in acetylcholine and dopamine, leading to tremors.
- B. there is a disruption in nerve impulse conduction, causing tremors.
- C. muscles are unable to receive impulses, resulting in tremors.
- D. the reflex arc is disrupted, leading to muscle tremors.
Correct answer: B
Rationale: In multiple sclerosis (MS), demyelination of neurons disrupts nerve impulse conduction. This disruption in nerve impulses can lead to tremors, explaining why the client experiences tremors in MS. Choice A is incorrect because tremors in MS are primarily due to nerve conduction issues, not an imbalance in acetylcholine and dopamine. Choice C is incorrect as it oversimplifies the process; the issue lies in nerve impulses, not the muscle's ability to receive them. Choice D is incorrect as the primary cause of tremors in MS is the disruption in nerve impulse conduction, not the reflex arc being disrupted.
5. The school nurse is teaching a group of adolescents about avoiding contaminated water during a mission trip. What should the nurse include in the teaching?
- A. Ice
- B. All are applicable
- C. Raw vegetables
- D. Unpeeled fruits
Correct answer: B
Rationale: The correct answer is B: All are applicable. Ice, raw vegetables, and unpeeled fruits can be sources of contamination in areas where water purity is questionable. It's safer to avoid these during a mission trip to prevent waterborne illnesses. Choice A (Ice), C (Raw vegetables), and D (Unpeeled fruits) are all potential sources of contamination in areas with questionable water quality. Including all these items in the teaching will help adolescents make informed decisions to stay healthy during their mission trip.
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