ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A client is scheduled for an electroencephalogram (EEG) and a nurse is providing teaching. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should not wash my hair prior to the procedure.
- B. I will receive a sedative 1 hour before the procedure.
- C. I should avoid eating prior to the procedure.
- D. I will be exposed to flashes of light during the procedure.
Correct answer: D
Rationale: The correct answer is D. The nurse should inform the client that flashes of light or pictures are often used during the procedure to assess the brain's response to stimuli. Choices A, B, and C are incorrect because washing hair, receiving a sedative, and avoiding eating are not directly related to the EEG procedure.
2. What is the primary nursing action for a patient experiencing continuous bubbling in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Clamp the chest tube
- C. Continue monitoring the chest tube
- D. Replace the chest tube system
Correct answer: A
Rationale: The correct answer is to tighten the connections of the chest tube system. Continuous bubbling in the chest tube water seal chamber indicates an air leak. By tightening the connections of the chest tube system, the nurse can often resolve the issue by ensuring there are no loose connections allowing air to enter. Clamping the chest tube or replacing the chest tube system are not appropriate actions in this situation. Clamping the tube can cause a dangerous buildup of pressure, while replacing the system should only be considered if tightening the connections does not resolve the air leak.
3. What dietary recommendations should be given to a patient with GERD?
- A. Avoid mint and spicy foods
- B. Eat large meals before bed
- C. Increase fluid intake during meals
- D. Drink milk as a snack
Correct answer: A
Rationale: The correct dietary recommendation for a patient with GERD is to avoid mint and spicy foods. These foods can trigger symptoms of GERD and lead to acid reflux. Choice B is incorrect because eating large meals before bed can exacerbate GERD symptoms by increasing the likelihood of acid reflux during sleep. Choice C is incorrect as increasing fluid intake during meals can worsen GERD symptoms by distending the stomach, leading to increased pressure on the lower esophageal sphincter. Choice D is also incorrect because while milk may provide temporary relief for some individuals, it is not a recommended long-term solution for managing GERD.
4. What should the healthcare provider do if a patient presents with chest pain and possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Administer aspirin
- C. Obtain cardiac enzymes
- D. Get IV access and auscultate heart sounds
Correct answer: A
Rationale: Administering sublingual nitroglycerin is the priority action in the treatment of chest pain in acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain. Aspirin can also be given to reduce clot formation, but nitroglycerin takes precedence in providing immediate relief. Obtaining cardiac enzymes and assessing heart sounds are important steps in the diagnostic process but do not address the immediate need to relieve chest pain and prevent cardiac tissue damage. Therefore, administering sublingual nitroglycerin is the most appropriate initial intervention for a patient presenting with chest pain and possible acute coronary syndrome.
5. What are the expected findings in a patient with a thrombotic stroke?
- A. Gradual loss of function on one side of the body
- B. Sudden loss of consciousness
- C. Severe headache and vomiting
- D. Loss of sensation in the affected limb
Correct answer: A
Rationale: The correct answer is A: Gradual loss of function on one side of the body. In a thrombotic stroke, a blood clot forms in an artery supplying blood to the brain, leading to reduced blood flow to a specific area of the brain. This results in a gradual onset of neurological deficits, such as weakness, numbness, or paralysis on one side of the body. Choices B, C, and D are incorrect because sudden loss of consciousness, severe headache and vomiting, and loss of sensation in the affected limb are more commonly associated with other types of strokes or medical conditions, not specifically thrombotic strokes. Thrombotic strokes typically present with gradual symptoms due to the gradual blockage of blood flow, leading to a progressive neurological deficit.
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