ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What dietary recommendations should be provided to a patient with GERD?
- A. Avoid mint and spicy foods
- B. Eat large meals before bed
- C. Consume liquids with meals
- D. Avoid foods high in potassium
Correct answer: A
Rationale: The correct recommendation for a patient with GERD is to avoid mint and spicy foods. These types of foods can trigger acid reflux and worsen GERD symptoms. Choice B is incorrect as eating large meals before bed can increase the likelihood of acid reflux due to increased pressure on the lower esophageal sphincter. Choice C is also incorrect as consuming liquids with meals can cause distension in the stomach, potentially leading to reflux. Choice D is not directly related to GERD, as foods high in potassium are generally healthy and not specifically problematic for GERD patients.
2. What is the priority action for a patient experiencing chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Administer aspirin
- C. Obtain IV access
- D. Check cardiac enzymes
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This medication helps to dilate the blood vessels, reduce the workload on the heart, and improve blood flow to the heart muscle, providing immediate relief for chest pain in acute coronary syndrome. Administering aspirin is also crucial in the early management of acute coronary syndrome to prevent further clot formation. However, in terms of immediate symptom relief, nitroglycerin takes precedence over aspirin. Obtaining IV access is important for administering medications and fluids but is not the priority over providing immediate relief for chest pain. Checking cardiac enzymes is essential for diagnosing acute coronary syndrome but is not the immediate priority when a patient is experiencing chest pain.
3. What is the initial nursing action for a patient with a chest tube found to have an air leak?
- A. Check the tube connections
- B. Replace the chest tube
- C. Remove and reinsert the chest tube
- D. Document the incident
Correct answer: A
Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.
4. 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.
5. When caring for a patient with a burn injury, what is the priority intervention?
- A. Monitor the burn area for infection
- B. Administer IV fluids
- C. Debride the burn area
- D. Apply a dry dressing
Correct answer: A
Rationale: The priority intervention when caring for a patient with a burn injury is to monitor the burn area for infection. This is crucial to prevent further complications such as sepsis. While administering IV fluids is important for fluid resuscitation, it is not the top priority compared to preventing infection. Debriding the burn area and applying a dry dressing are necessary interventions for wound care, but ensuring there is no infection takes precedence to avoid sepsis and other serious complications.
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