ATI RN TEST BANK

ATI Capstone Medical Surgical Assessment 2 Quizlet

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.

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.

What should the nurse do if a patient experiences abdominal cramping during enema administration?

  • A. Lower the height of the solution container
  • B. Increase the flow of the enema solution
  • C. Stop the procedure and remove the tubing
  • D. Continue the enema at a slower rate

Correct Answer: A
Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the solution container. This adjustment can help alleviate the cramping by reducing the speed and pressure of the solution entering the colon. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in extreme cases but is not the initial step. Continuing the enema at a slower rate (Choice D) may not effectively address the cramping, making it less optimal than lowering the height of the solution container.

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.

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.

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