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 does continuous bubbling in the water seal chamber of a chest tube indicate?
- A. An air leak
- B. A blockage in the chest tube
- C. Normal chest tube function
- D. Malfunction in the drainage system
Correct answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system. This bubbling occurs when air is escaping through the tube and entering the water seal chamber. Choice B, a blockage in the chest tube, is incorrect as continuous bubbling does not suggest a blockage. Choice C, normal chest tube function, is incorrect because continuous bubbling is not an expected finding in a properly functioning chest tube. Choice D, a malfunction in the drainage system, is incorrect as continuous bubbling specifically points towards an air leak, not a general malfunction.
3. A nurse misreads a glucose reading and administers insulin for a blood glucose of 210 instead of 120. What should the nurse monitor the patient for?
- A. Monitor for hyperglycemia
- B. Monitor for signs of hypoglycemia
- C. Administer glucose IV
- D. Document the incident
Correct answer: B
Rationale: The correct answer is B: Monitor for signs of hypoglycemia. The nurse should monitor the patient for hypoglycemia due to the administration of excess insulin. Administering insulin for a blood glucose level of 210 instead of 120 can lead to a rapid drop in blood sugar levels, causing hypoglycemia. Option A is incorrect as hyperglycemia is high blood sugar, which is unlikely in this scenario. Option C is incorrect as administering glucose IV would worsen the hypoglycemia. Option D is not the immediate priority; patient safety and monitoring for adverse effects take precedence.
4. What is the priority action if a patient experiences abdominal cramping during enema administration?
- A. Lower the height of the solution container
- B. Increase the flow of the enema solution
- C. Stop the procedure and remove the tubing
- D. Continue the enema at a slower rate
Correct answer: A
Rationale: During enema administration, if a patient experiences abdominal cramping, the priority action is to lower the height of the solution container. This adjustment can help relieve abdominal cramping by reducing the flow rate of the enema, making it more comfortable for the patient. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in some cases of severe discomfort or complications, but adjusting the height of the solution container should be the initial response. Continuing the enema at a slower rate (Choice D) may not address the immediate need to alleviate the cramping.
5. What is the preferred electrical intervention for a patient with ventricular tachycardia with a pulse?
- A. Defibrillation
- B. Synchronized cardioversion
- C. Pacing
- D. Medication administration
Correct answer: B
Rationale: Synchronized cardioversion is the preferred electrical intervention for ventricular tachycardia with a pulse. In this scenario, the heart still has an organized rhythm, so synchronized cardioversion is used to deliver a shock at a specific point in the cardiac cycle, aiming to restore a normal rhythm. Defibrillation (Choice A) is used for pulseless ventricular tachycardia or ventricular fibrillation. Pacing (Choice C) may be used for bradycardias or certain types of heart blocks. Medication administration (Choice D) can be considered for stable ventricular tachycardia, but synchronized cardioversion is the primary intervention for ventricular tachycardia with a pulse.
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