ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. 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.
2. A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?
- A. The dressing was changed 7 days ago
- B. The circumference of the client's upper arm has increased by 10%
- C. The catheter has not been used in 8 hours
- D. The catheter has been flushed with 10 mL of sterile saline after medication use
Correct answer: B
Rationale: An increase in the circumference of the client's upper arm by 10% could indicate deep vein thrombosis, which is a serious condition. Deep vein thrombosis can impede blood flow and potentially lead to life-threatening complications. Therefore, the nurse should notify the provider immediately about this finding. Choice A is not an immediate concern as PICC dressing changes are usually done every 7 days. Choice C is a normal finding as catheters may not be used for certain periods. Choice D is a correct procedure for maintaining catheter patency after medication use.
3. What dietary teaching should be provided to a patient with GERD?
- A. Avoid mint and pepper
- B. Consume liquids with meals
- C. Increase fluid intake with meals
- D. Eat large meals before bed
Correct answer: A
Rationale: The correct dietary teaching for a patient with GERD is to avoid mint and pepper. Mint and pepper can trigger reflux symptoms and increase gastric acid secretion, exacerbating GERD. Choices B and C are not recommended for patients with GERD as consuming liquids with meals and increasing fluid intake during meals can contribute to reflux by distending the stomach. Choice D, eating large meals before bed, can also worsen GERD symptoms by increasing pressure on the lower esophageal sphincter and promoting reflux.
4. What recommendations should the nurse provide to a patient diagnosed with GERD?
- A. Avoid items like mint that increase gastric acid secretion
- B. Eat small, frequent meals
- C. Avoid eating 1 hour before bedtime
- D. Avoid black and red pepper
Correct answer: A
Rationale: The correct answer is A: 'Avoid items like mint that increase gastric acid secretion.' Mint can relax the lower esophageal sphincter, leading to increased gastric acid secretion and worsening GERD symptoms. Choice B is a good recommendation for GERD management as it helps prevent excessive stomach distension. Choice C is also a recommended practice to avoid reflux during sleep. Choice D, avoiding black and red pepper, is not directly linked to exacerbating GERD symptoms, so it is not the most relevant recommendation for a patient diagnosed with GERD.
5. What does continuous bubbling in the chest tube water seal chamber indicate?
- A. An air leak
- B. Normal chest tube function
- C. A blocked chest tube
- D. Continuous drainage from the chest tube
Correct answer: A
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system. This occurs when air is entering the system from the outside, preventing the lung from fully re-expanding. Choice B is incorrect because continuous bubbling is not a sign of normal chest tube function. Choice C is incorrect because a blocked chest tube would typically exhibit no bubbling or fluctuation in the water seal chamber. Choice D is incorrect as continuous drainage would not cause bubbling in the water seal chamber.
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