ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A nurse is providing discharge teaching to a client who is starting to take carbidopa/levodopa to treat Parkinson's disease. Which of the following instructions should the nurse include in the teaching?
- A. This medication can cause your urine to turn a dark color.
- B. Expect immediate relief after taking this medication.
- C. Take the medication with a high protein food.
- D. Skip a dose of the medication if you experience dizziness.
Correct answer: A
Rationale: The correct instruction to include in the teaching is that carbidopa/levodopa can cause the client's urine to turn a dark color, which is a harmless effect. It is crucial for the nurse to educate the client about this common side effect. Choice B is incorrect because immediate relief is not expected; therapeutic effects may take weeks to months. Choice C is incorrect as carbidopa/levodopa should be taken on an empty stomach to enhance absorption. Choice D is incorrect as the client should not skip doses without consulting their healthcare provider, even if they experience dizziness.
2. What is the first medication to give to a patient experiencing wheezing due to an allergic reaction?
- A. Albuterol via nebulizer
- B. Cromolyn 20 mg via nebulizer
- C. Methylprednisolone 100 mg IV
- D. Aminophylline 500 mg IV
Correct answer: A
Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction due to its rapid action in opening airways. Cromolyn (Choice B) is used for prevention rather than acute treatment. Methylprednisolone (Choice C) and Aminophylline (Choice D) are not the first-line treatments for acute wheezing in allergic reactions.
3. What teaching should be provided to a patient following surgical removal of a cataract?
- A. Avoid NSAIDs
- B. Wear dark glasses while outdoors
- C. Creamy white drainage is normal
- D. Reduce phosphorus intake to 700 mg/day
Correct answer: A
Rationale: The correct teaching to provide to a patient following surgical removal of a cataract is to avoid NSAIDs. NSAIDs can increase the risk of bleeding at the surgical site, so it is important to steer clear of them. Choice B, wearing dark glasses while outdoors, may be recommended post-surgery to protect the eyes from bright light, but it is not the priority teaching in this case. Choice C, stating that creamy white drainage is normal, is not accurate as drainage from the eye should be monitored and reported. Choice D, reducing phosphorus intake to 700 mg/day, is unrelated to post-cataract surgery care and is not a necessary teaching point.
4. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?
- A. Inspect the pin site every 4 hours
- B. Monitor the client's skin under the halo vest
- C. Ensure two personnel hold the halo device when repositioning the client
- D. Apply powder to the client's skin under the vest to decrease itching
Correct answer: B
Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.
5. What does continuous bubbling in the water seal chamber of a chest tube indicate?
- A. An air leak
- B. A blocked chest tube
- C. Normal chest tube function
- D. Continuous drainage from the chest tube
Correct answer: A
Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak in the system. This occurs when air is entering the system through a leak, preventing the lung from fully re-expanding. Choice B, a blocked chest tube, is incorrect as a blocked tube would result in a lack of drainage rather than continuous bubbling. Choice C, normal chest tube function, is incorrect as continuous bubbling signifies an issue. Choice D, continuous drainage from the chest tube, is incorrect as bubbling in the water seal chamber specifically indicates an air leak, not just the presence of drainage.
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