ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What medication should be given first to a patient experiencing wheezing and coughing due to an allergic reaction?
- A. Albuterol 3 ml via nebulizer
- B. Cromolyn via nebulizer
- C. Aminophylline IV
- D. Methylprednisolone 100 mg IV
Correct answer: A
Rationale: The correct answer is Albuterol 3 ml via nebulizer. Albuterol is a bronchodilator that helps relieve wheezing and coughing by opening up the airways, making it the first-line treatment for allergic reactions presenting with these symptoms. Cromolyn and aminophylline are not typically used as first-line treatments for acute allergic reactions with wheezing and coughing. Methylprednisolone, a corticosteroid, may be beneficial for inflammation in the setting of an allergic reaction but is not the initial medication of choice to address wheezing and coughing.
2. What are the manifestations of osteomyelitis?
- A. Localized pain, swelling, erythema
- B. Elevated white blood cells
- C. Elevated calcium levels
- D. Low potassium levels
Correct answer: A
Rationale: Osteomyelitis often manifests as localized pain, swelling, and erythema due to infection in the bone. These symptoms are characteristic of inflammation and infection in the bone tissue. Elevated white blood cells (Choice B) may be present as part of the body's immune response to the infection but are not specific manifestations of osteomyelitis. Elevated calcium levels (Choice C) and low potassium levels (Choice D) are not typically associated with osteomyelitis.
3. A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?
- A. Flail chest
- B. Hemothorax
- C. Pulmonary contusion
- D. Pneumothorax
Correct answer: A
Rationale: The correct answer is A: Flail chest. Flail chest results from multiple rib fractures, causing paradoxical chest movement where the injured part moves inward during inspiration and outward during expiration, interfering with ventilation. Choice B, Hemothorax, involves blood in the pleural cavity and does not typically cause paradoxical chest movement. Choice C, Pulmonary contusion, is a bruise to the lung tissue and does not present with paradoxical chest movement. Choice D, Pneumothorax, is the presence of air in the pleural space, leading to lung collapse, but it does not demonstrate paradoxical chest movement like in flail chest.
4. A client has a Transient Ischemic Attack (TIA). What should the nurse teach?
- A. Avoid eating within 3 hours of bedtime
- B. Consume liquids between meals
- C. Eat large meals to increase caloric intake
- D. Avoid liquids to prevent aspiration
Correct answer: A
Rationale: The correct answer is A: Avoid eating within 3 hours of bedtime. For a client with a Transient Ischemic Attack (TIA), it is crucial to avoid eating within 3 hours of bedtime to reduce reflux that can worsen symptoms. Choice B is incorrect because consuming liquids between meals is not specifically related to managing TIA. Choice C is incorrect as eating large meals may not be recommended, especially if the client needs to watch their caloric intake. Choice D is incorrect because avoiding liquids entirely can lead to dehydration and is not a standard recommendation for TIA management.
5. What are the expected signs of increased intracranial pressure (IICP)?
- A. Restlessness, confusion, irritability
- B. Severe headache and confusion
- C. Elevated blood pressure and bradycardia
- D. Bradycardia and altered pupil response
Correct answer: A
Rationale: The correct answer is A: Restlessness, confusion, irritability. These are early signs of increased intracranial pressure (IICP) and require prompt intervention. Restlessness, confusion, and irritability are indicative of the brain's attempt to compensate for the rising pressure. Choice B is incorrect because severe headache alone is not specific to IICP and can be present in various conditions. Choice C is incorrect because elevated blood pressure is not a common sign of IICP; instead, hypertension may be present in the compensatory stage. Choice D is incorrect as bradycardia and altered pupil response are signs of advanced IICP, not early signs. Monitoring and recognizing these early signs are crucial for timely intervention and preventing further complications.
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