ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What is the primary nursing action for a patient experiencing continuous bubbling in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Clamp the chest tube
- C. Continue monitoring the chest tube
- D. Replace the chest tube system
Correct answer: A
Rationale: The correct answer is to tighten the connections of the chest tube system. Continuous bubbling in the chest tube water seal chamber indicates an air leak. By tightening the connections of the chest tube system, the nurse can often resolve the issue by ensuring there are no loose connections allowing air to enter. Clamping the chest tube or replacing the chest tube system are not appropriate actions in this situation. Clamping the tube can cause a dangerous buildup of pressure, while replacing the system should only be considered if tightening the connections does not resolve the air leak.
2. The belief that effort will lead to a specific performance level in an individual is known as:
- A. Rewards.
- B. Expectancy.
- C. Valence.
- D. Instrumentality.
Correct answer: B
Rationale: The correct answer is B: Expectancy. Expectancy refers to the perceived probability that effort will lead to a specific performance level. This aligns with the concept of expectancy theory in psychology, which emphasizes the importance of individuals' beliefs regarding the link between effort and outcomes. Choices A, C, and D are incorrect. Rewards (choice A) typically refer to incentives given after achieving a goal, valence (choice C) is the value a person places on a particular outcome, and instrumentality (choice D) is the belief that a particular outcome is contingent on achieving a specific level of performance.
3. A client with brain cancer and headaches is prescribed dexamethasone. What is the purpose of this adjuvant medication?
- A. To decrease inflammation and swelling
- B. To improve concentration
- C. To induce sedation
- D. To treat depression
Correct answer: A
Rationale: Dexamethasone, a glucocorticoid, is indicated for clients with brain cancer to decrease inflammation and swelling. It helps reduce cerebral edema and relieve pressure caused by the tumor, ultimately alleviating headaches. The purpose of prescribing dexamethasone in this case is not to improve concentration (choice B), induce sedation (choice C), or treat depression (choice D). Methylphenidate, a stimulant, is used for conditions like ADHD, not for brain cancer. Hydroxyzine, an antihistamine, is primarily used for anxiety and itching, not for brain cancer. Amitriptyline, a tricyclic antidepressant, is used for conditions like depression and neuropathic pain, not specifically for brain cancer-related headaches.
4. A nurse is planning teaching for the parents of a toddler who follows a vegetarian diet. The nurse should plan to include which of the following foods as the best source of dietary protein for the child?
- A. Soy milk
- B. Peanut butter
- C. Dried beans
- D. Whole grains
Correct answer: C
Rationale: Dried beans are the best source of dietary protein for a toddler following a vegetarian diet. They are rich in protein and other essential nutrients. Soy milk, while a good source of protein, may not provide as much protein density as dried beans. Peanut butter is a good source of protein but may not be as protein-dense as dried beans. Whole grains are not as high in protein content compared to dried beans, making them a less optimal choice for meeting the toddler's protein needs.
5. What complication of wound healing is an abnormal passage that connects two body cavities or a cavity and the skin?
- A. Fistula
- B. Hemorrhage
- C. Evisceration
- D. infection
Correct answer: Fistula
Rationale:
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