ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What is the correct response when a patient receiving an enema reports abdominal cramping?
- A. Lower the height of the enema container
- B. Stop the enema procedure
- C. Remove the enema tubing
- D. Continue the enema at a slower rate
Correct answer: A
Rationale: The correct response when a patient receiving an enema reports abdominal cramping is to lower the height of the enema container. Lowering the height reduces the flow rate, which can help relieve cramping. Stopping the procedure (choice B) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (choice C) is not the initial step to take when addressing abdominal cramping during an enema. Continuing the enema at a slower rate (choice D) might not be as effective as lowering the height of the container to alleviate cramping.
2. What is the correct action when a patient reports 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: The correct action to take when a patient reports cramping during enema administration is to lower the height of the solution container. Lowering the height reduces the pressure and speed of the solution entering the rectum, alleviating cramping. Increasing the flow of the enema solution (Choice B) can worsen the discomfort. Stopping the procedure and removing the tubing (Choice C) is not necessary unless there are severe complications. Continuing the enema at a slower rate (Choice D) may not effectively address the immediate cramping issue and could still cause discomfort to the patient.
3. What ECG changes are expected in a patient with hypokalemia?
- A. Flattened T waves
- B. Prominent U waves
- C. Widened QRS complexes
- D. Tall T waves
Correct answer: A
Rationale: Flattened T waves are an early indicator of hypokalemia on an ECG. Hypokalemia primarily presents with flattened T waves, not prominent U waves, widened QRS complexes, or tall T waves. Prominent U waves are associated with hypokalemia only in severe cases. Widened QRS complexes are more indicative of hyperkalemia, while tall T waves are seen in hyperkalemia as well.
4. 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.
5. What should the nurse do when continuous bubbling is seen 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
- D. Continue monitoring the chest tube
Correct answer: A
Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the nurse should tighten the connections of the chest tube system. This action can often resolve an air leak causing the continuous bubbling. Clamping the chest tube or replacing it would not address the underlying issue of an air leak and may lead to complications. Continuing to monitor the chest tube without taking corrective action may result in the deterioration of the patient's condition.
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