ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What intervention is needed for continuous bubbling in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Clamp the chest tube
- C. Replace the chest tube system
- D. Continue monitoring the chest tube
Correct answer: A
Rationale: The correct intervention for continuous bubbling in the chest tube water seal chamber is to tighten the connections of the chest tube system. Continuous bubbling indicates an air leak in the system, and tightening the connections can help resolve this issue. Clamping the chest tube (Choice B) is not appropriate and can lead to complications by obstructing the drainage system. Similarly, replacing the entire chest tube system (Choice C) may not be necessary if the issue can be resolved by tightening the connections. Continuing to monitor the chest tube (Choice D) without taking action to address the continuous bubbling may delay necessary interventions to prevent complications.
2. A 55-year-old man presents with a history of fatigue, weight loss, and night sweats. He reports recent onset of a productive cough and hemoptysis. Which condition should the nurse suspect?
- A. Lung cancer
- B. Pneumonia
- C. Tuberculosis
- D. Pulmonary embolism
Correct answer: C
Rationale: The correct answer is C: Tuberculosis. The symptoms described - fatigue, weight loss, night sweats, productive cough, and hemoptysis - are classic manifestations of tuberculosis. Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis, commonly affecting the lungs but can also involve other organs. **Choice A: Lung cancer** typically presents with symptoms like persistent cough, chest pain, and shortness of breath, but it is less likely in this case due to the presence of hemoptysis. **Choice B: Pneumonia** can present with productive cough, fever, and chest pain, but it is less likely given the chronicity of symptoms and the presence of hemoptysis. **Choice D: Pulmonary embolism** usually presents with sudden onset shortness of breath, chest pain, and can be associated with risk factors like recent surgery or immobility.
3. The purpose of chest percussion and vibration is to loosen secretions in the lungs. The difference between the procedures is:
- A. Percussion uses only one hand, while vibration uses both hands
- B. Percussion delivers cushioned blows to the chest with cupped palms, while vibration gently shakes secretions loose
- C. In both percussion and vibration, the hands are not on top of each other, and hand action is not in tune with the client's breath
- D. Percussion slaps the chest to loosen secretions, while vibration shakes the secretions along with the inhalation
Correct answer: D
Rationale: Chest percussion involves the use of rhythmic tapping to dislodge mucus from the lungs, facilitating its movement toward the larger airways where it can be expelled. This technique is particularly important in conditions where mucus retention is a significant risk factor for infection. The key difference between chest percussion and vibration is that percussion involves slapping the chest to loosen secretions, while vibration involves shaking the secretions along with the inhalation, aiding in moving the loosened secretions upwards for easier removal. Choices A, B, and C do not accurately describe the main difference between chest percussion and vibration, making them incorrect.
4. Staff are sometimes injured when a patient or visitor becomes agitated. If a staff member reports an injury, the following actions should take place: (EXCEPT)
- A. Notify security.
- B. Complete an incident report.
- C. Notify the nursing supervisor.
- D. Ensure that staff has been examined.
Correct answer: B
Rationale: When a staff member reports an injury resulting from an agitated patient or visitor, several actions should be taken. These actions include notifying security to ensure safety, notifying the nursing supervisor for appropriate follow-up, and ensuring that the injured staff member has been examined to assess the extent of the injury. Completing an incident report is not the correct action to exclude because documenting the incident is crucial for legal and healthcare purposes. Incident reports provide a detailed account of what occurred, which is essential for investigations, insurance claims, and improving safety protocols. Therefore, all other options are necessary steps to take when a staff member reports an injury, making completing an incident report the correct answer for exclusion.
5. The counting of sponges is done by the Surgeon together with the:
- A. Circulating nurse
- B. Scrub nurse
- C. Assistant surgeon
- D. Nurse supervisor
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
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