ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What is the expected finding in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized swelling and redness
- C. Numbness and tingling
- D. Fever and infection
Correct answer: A
Rationale: In a patient with compartment syndrome, the expected finding includes unrelieved pain, pallor, and pulselessness. These are classic signs of compartment syndrome and indicate compromised blood flow and tissue perfusion, necessitating urgent intervention. Choices B, C, and D are incorrect because localized swelling and redness, numbness and tingling, as well as fever and infection, are not typical findings associated with compartment syndrome.
2. A nurse is providing teaching to a client who was newly diagnosed with nephrotic syndrome. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. I can expect swelling in my hands and on my face.
- B. The amount of protein in my blood is high.
- C. I might have some pain and gas in my stomach from this condition.
- D. I will use a soft bristle toothbrush to prevent bleeding gums.
Correct answer: A
Rationale: The correct answer is A. Nephrotic syndrome leads to edema, especially of the face and dependent areas, due to the loss of protein in the urine. Choice B is incorrect because nephrotic syndrome leads to protein loss in the urine, not an increase in blood protein levels. Choice C is incorrect as stomach pain and gas are not typical symptoms of nephrotic syndrome. Choice D is incorrect as using a soft bristle toothbrush is not directly related to the manifestations of nephrotic syndrome.
3. A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 minutes. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer?
- A. Diazepam IV
- B. Lorazepam PO
- C. Diltiazem IV
- D. Clonazepam PO
Correct answer: A
Rationale: In the scenario described, where the client has been experiencing repeated tonic-clonic seizures over an extended period, the priority is to administer a medication that can rapidly terminate the seizures. Diazepam is the medication of choice for status epilepticus due to its rapid onset of action within 10 minutes when administered intravenously. Lorazepam is also an option, but it is typically administered intravenously as well. Diltiazem is a calcium channel blocker used for conditions like hypertension and angina, not for seizures. Clonazepam, although used for seizures, is not the ideal choice in this acute situation due to its slower onset of action compared to benzodiazepines like diazepam and lorazepam.
4. What precaution should be advised to a patient following a cataract surgery?
- A. Wear dark glasses while outdoors
- B. Avoid NSAIDs
- C. Use warm compresses
- D. Apply cold packs
Correct answer: A
Rationale: Following cataract surgery, patients are advised to wear dark glasses while outdoors. This is crucial to protect the eyes from bright light and prevent complications such as excessive glare or discomfort. Choice B, avoiding NSAIDs, is not directly related to post-cataract surgery care. Choices C and D, using warm compresses and applying cold packs, are not typically part of the standard post-operative care for cataract surgery.
5. A patient who received an enema reports abdominal cramping. What should the nurse do?
- A. Increase the flow of the enema solution
- B. Lower the height of the enema solution container
- C. Remove the enema tubing
- D. Stop the procedure
Correct answer: B
Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.
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