ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. When providing discharge teaching to a patient who underwent cataract surgery, what should the patient avoid?
- A. Avoid NSAIDs
- B. Avoid bright lights
- C. Avoid alcohol
- D. Avoid phosphorus-rich foods
Correct answer: A
Rationale: The correct answer is to avoid NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding after cataract surgery due to their anticoagulant properties. Bright lights (choice B) are not contraindicated post-cataract surgery unless the patient experiences discomfort or sensitivity. Alcohol consumption (choice C) is generally not restricted after cataract surgery, but moderation is recommended. Phosphorus-rich foods (choice D) are not directly related to cataract surgery postoperative care.
2. What is the priority action for a patient experiencing chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Obtain IV access
- C. Check the patient's cardiac enzymes
- D. Administer aspirin
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. Nitroglycerin helps relieve chest pain by dilating blood vessels and improving blood flow to the heart, which is crucial in managing acute coronary syndrome. While obtaining IV access and checking cardiac enzymes are important steps in the assessment and management of acute coronary syndrome, administering nitroglycerin takes precedence to alleviate symptoms and reduce cardiac tissue damage. Administering aspirin is also essential in the treatment of acute coronary syndrome, but it is not the immediate priority in this scenario.
3. What is the purpose of an escharotomy in burn management?
- A. To relieve pressure and improve circulation in burn injuries
- B. To remove necrotic tissue from a wound
- C. To prevent infection in burn injuries
- D. To remove excess fluid from burn wounds
Correct answer: A
Rationale: An escharotomy is performed to relieve pressure in areas affected by deep burns and improve circulation. This procedure involves making incisions through the eschar (burned and dead tissue) to release constricting tissue and allow for the return of blood flow. Choice B is incorrect because the removal of necrotic tissue is typically done through debridement, not escharotomy. Choice C is incorrect because preventing infection in burn injuries is usually achieved through proper wound care and antibiotic therapy, not escharotomy. Choice D is incorrect because removing excess fluid from burn wounds is managed through methods like fluid resuscitation and monitoring, not escharotomy.
4. A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO2 29 mm Hg, and HCO3- 25 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct answer: B
Rationale: The correct answer is B: Respiratory alkalosis. In this scenario, the client is experiencing respiratory alkalosis due to hyperventilation. Hyperventilation leads to excessive loss of carbon dioxide, causing a decrease in hydrogen ion concentration and an increase in pH levels. Choices A, C, and D are incorrect. Respiratory acidosis is characterized by high PaCO2 and low pH. Metabolic acidosis is associated with low HCO3- levels and low pH. Metabolic alkalosis is marked by high HCO3- levels and high pH. In this case, the ABG results indicate respiratory alkalosis.
5. What is the priority intervention for a patient with unstable angina?
- A. Administer nitroglycerin
- B. Establish IV access
- C. Auscultate heart sounds
- D. Administer aspirin
Correct answer: A
Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with unstable angina as it helps dilate blood vessels, improve blood flow to the heart, relieve chest pain, and prevent further cardiac damage. Establishing IV access (choice B) may be important but is not the priority over administering nitroglycerin in this scenario. Auscultating heart sounds (choice C) and administering aspirin (choice D) are also important aspects of managing unstable angina, but they are not the immediate priority intervention when a patient is experiencing chest pain.
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