ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What should a healthcare professional monitor in a patient receiving insulin who is at risk for hypoglycemia?
- A. Monitor blood glucose levels
- B. Monitor for respiratory distress
- C. Monitor for muscle weakness
- D. Monitor for hyperkalemia
Correct answer: A
Rationale: Monitoring blood glucose levels is crucial in patients receiving insulin who are at risk for hypoglycemia. Insulin can lower blood sugar levels, potentially leading to hypoglycemia, which can be harmful if not promptly recognized and managed. Checking blood glucose levels allows for early detection of low blood sugar levels, enabling timely interventions to prevent complications. Choices B, C, and D are incorrect as they do not directly relate to monitoring for hypoglycemia in patients receiving insulin.
2. What is the initial nursing action for a patient with a chest tube found to have an air leak?
- A. Check the tube connections
- B. Replace the chest tube
- C. Remove and reinsert the chest tube
- D. Document the incident
Correct answer: A
Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.
3. What are the dietary recommendations for a patient with GERD?
- A. Avoid mint and spicy foods
- B. Eat large meals before bedtime
- C. Consume liquids with meals
- D. Avoid NSAIDs
Correct answer: A
Rationale: The correct answer is to avoid mint and spicy foods for a patient with GERD. These foods can increase gastric acid secretion and worsen symptoms of GERD. Choice B is incorrect because eating large meals before bedtime can exacerbate GERD symptoms due to increased gastric pressure when lying down. Choice C is also incorrect as consuming liquids with meals can lead to increased gastric distention, potentially triggering GERD symptoms. Choice D, avoiding NSAIDs, though important for some patients with GERD due to their potential to irritate the stomach lining, is not a general dietary recommendation for all GERD patients.
4. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider?
- A. Breath sounds
- B. Temperature
- C. Blood pressure
- D. Creatine kinase
Correct answer: A
Rationale: The correct answer is A: Breath sounds. When caring for a client with unstable angina, changes in breath sounds could indicate left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. Reporting any abnormalities in breath sounds promptly to the provider is crucial to prevent further complications. Choices B, C, and D are not directly related to the immediate management of unstable angina. Temperature, blood pressure, and creatine kinase levels are important parameters to monitor but are not the priority in this situation.
5. 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.
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