ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What are the common manifestations of compartment syndrome?
- A. Unrelieved pain, pallor, pulselessness
- B. Redness and swelling
- C. Fever and infection
- D. Swelling and redness
Correct answer: A
Rationale: The correct manifestations of compartment syndrome are unrelieved pain, pallor, and pulselessness. These symptoms indicate compromised blood flow and neurovascular compromise, necessitating immediate medical intervention. Redness and swelling (Choice B) are more commonly associated with inflammation or infection rather than compartment syndrome. Fever and infection (Choice C) are not typical manifestations of compartment syndrome. Swelling and redness (Choice D) are general signs that can be seen in various conditions and are not specific to compartment syndrome.
2. 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.
3. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites. Which of the following instructions should the nurse include in the teaching?
- A. Apply an ice pack directly to the affected area
- B. Immobilize the affected extremity with a splint
- C. Place a tourniquet above and below the affected area
- D. Elevate the affected extremity
Correct answer: B
Rationale: The correct answer is to immobilize the affected extremity with a splint. This helps to slow the spread of venom by limiting movement. Applying an ice pack directly to the affected area (Choice A) is not recommended for snake bites as it could exacerbate tissue damage. Placing a tourniquet above and below the affected area (Choice C) is also not advised as it can lead to further complications. Elevating the affected extremity (Choice D) is not recommended for snake bites; keeping it below the level of the heart is more appropriate to reduce venom spread.
4. What does continuous bubbling in the water seal chamber of a chest tube indicate?
- A. An air leak
- B. Normal chest tube function
- C. A blockage in the chest tube
- D. A malfunction in the drainage system
Correct answer: A
Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This bubbling occurs when air leaks from the patient's pleural space into the chest tube system. It is essential to address this issue promptly to prevent complications like a pneumothorax. Choices B, C, and D are incorrect because continuous bubbling in the water seal chamber is not indicative of normal chest tube function, a blockage in the chest tube, or a malfunction in the drainage system.
5. What are the expected symptoms in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized swelling and redness
- C. Fever and swelling
- D. Weakness and fatigue
Correct answer: A
Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. These symptoms are classic signs of compartment syndrome, which is a serious condition characterized by reduced circulation in a closed muscle compartment. The pain is typically severe and disproportionate to the injury, and if left untreated, it can lead to tissue damage and loss of function. Choices B, C, and D are incorrect because they do not represent the hallmark symptoms of compartment syndrome. Localized swelling and redness may be present but are not specific to this condition. Fever and swelling are more indicative of inflammation or infection, while weakness and fatigue are nonspecific and do not typically occur in isolation in compartment syndrome.
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