ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. A patient with GERD is being taught by a nurse. What should the patient avoid?
- A. Avoid mint and pepper
- B. Increase water intake during meals
- C. Eat frequent small meals
- D. Consume more spicy foods
Correct answer: A
Rationale: Patients with GERD should avoid mint and spicy foods as they can trigger reflux. Choice B ('Increase water intake during meals') is not recommended for GERD patients as it can worsen symptoms by distending the stomach. Choice C ('Eat frequent small meals') is beneficial for GERD patients to prevent excessive stomach distension. Choice D ('Consume more spicy foods') is incorrect as spicy foods can exacerbate GERD symptoms.
2. What is an escharotomy and when is it performed?
- A. A surgical incision to release pressure in burn injuries
- B. A procedure to remove dead tissue from wounds
- C. An incision to improve circulation in tight skin after burns
- D. A procedure to remove excess fluid from the chest
Correct answer: A
Rationale: An escharotomy is a surgical incision made to release pressure in a part of the body that has a deep burn and excessive swelling. This procedure is crucial in preventing further damage due to restricted blood flow and compromised circulation. Choice B is incorrect because it describes debridement, which is the removal of dead tissue from wounds. Choice C is incorrect as it does not specifically address the purpose of relieving pressure in burn injuries. Choice D is incorrect as it describes a procedure more related to thoracentesis, which is the removal of excess fluid from the chest, typically the pleural space.
3. What dietary changes should be implemented for a patient with GERD?
- A. Avoid mint and spicy foods
- B. Eat large meals before bedtime
- C. Consume liquids with meals
- D. Drink milk as a snack
Correct answer: A
Rationale: The correct answer is A: Avoid mint and spicy foods. Patients with GERD should avoid mint and spicy foods because they can increase gastric acid production, exacerbating symptoms. Choice B is incorrect because eating large meals before bedtime can worsen GERD symptoms due to lying down with a full stomach. Choice C is incorrect as consuming liquids with meals can lead to increased pressure on the lower esophageal sphincter, promoting acid reflux. Choice D is also incorrect as drinking milk as a snack is not recommended for GERD patients, as it may temporarily soothe symptoms but can ultimately stimulate acid production.
4. A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?
- A. Place several pillows behind the client's head
- B. Place the client in a Sim's position
- C. Keep the client's neck in a midline position
- D. Maintain flexion of the client's hips at a 90° angle
Correct answer: C
Rationale: Keeping the client's neck in a midline position is crucial for managing increased intracranial pressure. This position helps optimize blood flow and minimizes the risk of further increasing ICP. Placing several pillows behind the client's head (Choice A) may inadvertently elevate the head, potentially worsening ICP. Placing the client in a Sim's position (Choice B) or maintaining flexion of the client's hips at a 90° angle (Choice D) are not directly related to managing increased ICP.
5. What is the most likely cause of continuous bubbling in the water seal chamber of a chest tube?
- A. An air leak
- B. A blockage in the chest tube
- C. Normal chest tube function
- D. Drainage from the chest tube
Correct answer: A
Rationale: Continuous bubbling in the water seal chamber of a chest tube usually indicates an air leak. An air leak can disrupt the negative pressure required for the chest tube to function properly, leading to inadequate drainage and potential complications. A blockage in the chest tube would typically result in decreased or absent drainage rather than continuous bubbling. Normal chest tube function does not involve continuous bubbling in the water seal chamber. Drainage from the chest tube may lead to fluid moving into the drainage system, but it would not cause continuous bubbling in the water seal chamber.
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