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. A client is being taught about fecal occult blood testing (FOBT) for colorectal cancer screening. Which of the following statements should the nurse include in the teaching?
- A. Your provider will use a stool sample obtained during a digital rectal examination to perform the test.
- B. Your provider will recommend a stimulant laxative before the test to empty the bowel.
- C. You should start annual fecal occult blood testing for colorectal cancer screening at the age of 40.
- D. You should avoid corticosteroids before the test.
Correct answer: D
Rationale: The correct answer is D because the nurse should advise the client to avoid corticosteroids, anti-inflammatory medications, and vitamin C before fecal occult blood testing to prevent false-positive results. Choice A is incorrect as stool samples for FOBT are usually collected using a kit at home. Choice B is incorrect because stimulant laxatives are not typically used before FOBT. Choice C is incorrect as guidelines recommend starting colorectal cancer screening at the age of 50, not 40.
3. A patient reports abdominal cramping after enema administration. What is the appropriate action?
- A. Lower the height of the solution container
- B. Stop the procedure and remove tubing
- C. Increase the flow of enema solution
- D. Continue the enema at a slower rate
Correct answer: A
Rationale: Lowering the height of the enema solution container is the appropriate action when a patient reports abdominal cramping after enema administration. This helps reduce the flow rate of the solution, potentially alleviating the cramping. Stopping the procedure and removing tubing (Choice B) would be too abrupt and may not address the issue. Increasing the flow of enema solution (Choice C) could exacerbate the cramping by adding more pressure. Continuing the enema at a slower rate (Choice D) might not provide immediate relief compared to lowering the height of the solution container.
4. What is the first nursing action for a patient admitted with chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Check the patient's urine output
- C. Administer IV fluids
- D. Obtain cardiac enzymes
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action for a patient admitted with chest pain from acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. Checking the patient's urine output (Choice B) is not the priority in this situation. Administering IV fluids (Choice C) may not be necessary unless indicated by the patient's condition. Obtaining cardiac enzymes (Choice D) is important but is not the initial action needed to address the patient's acute symptoms.
5. What is the priority action if a patient experiences hypoglycemia after an insulin dose?
- A. Check the patient's blood glucose level
- B. Administer IV dextrose
- C. Document the incident
- D. Continue monitoring the patient
Correct answer: A
Rationale: The priority action when a patient experiences hypoglycemia after an insulin dose is to check the patient's blood glucose level. This is crucial to confirm hypoglycemia before initiating any treatment. While administering IV dextrose may be necessary if the patient's blood glucose level is critically low, confirming hypoglycemia is essential to guide appropriate interventions. Documenting the incident is important for documentation purposes but is not the immediate priority when the patient's safety is at risk. Continuing to monitor the patient is essential, but it should follow the confirmation and initial management of hypoglycemia.
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