ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What should be included in teaching for a patient with pre-dialysis end-stage kidney disease?
- A. Limit phosphorus intake to 700 mg/day
- B. Increase protein intake to 1g/kg/day
- C. Increase sodium intake
- D. Limit sodium to 1,500 mg/day
Correct answer: A
Rationale: The correct answer is to limit phosphorus intake to 700 mg/day for a patient with pre-dialysis end-stage kidney disease. Excessive phosphorus intake can lead to further complications in kidney disease, such as bone and cardiovascular issues. Choice B is incorrect as increasing protein intake can put additional stress on the kidneys due to the buildup of urea and other waste products. Choice C is incorrect because increasing sodium intake can worsen hypertension and fluid retention, common issues in kidney disease. Choice D is incorrect as limiting sodium intake is generally recommended in kidney disease to manage blood pressure and fluid balance.
2. What is an escharotomy and when is it performed?
- A. A surgical incision to release pressure in burn injuries
- B. A procedure to remove dead tissue from wounds
- C. An incision to improve circulation in tight skin after burns
- D. A procedure to remove excess fluid from the chest
Correct answer: A
Rationale: An escharotomy is a surgical incision made to release pressure in a part of the body that has a deep burn and excessive swelling. This procedure is crucial in preventing further damage due to restricted blood flow and compromised circulation. Choice B is incorrect because it describes debridement, which is the removal of dead tissue from wounds. Choice C is incorrect as it does not specifically address the purpose of relieving pressure in burn injuries. Choice D is incorrect as it describes a procedure more related to thoracentesis, which is the removal of excess fluid from the chest, typically the pleural space.
3. 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.
4. What should the nurse do when a patient experiences abdominal cramping during enema administration?
- A. Lower the height of the enema solution container
- B. Stop the procedure and remove the tubing
- C. Continue the enema at a slower rate
- D. Increase the flow of the enema solution
Correct answer: A
Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. Lowering the height helps relieve cramping by slowing down the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is incorrect as it does not directly address the cramping issue. Choice C, continuing the enema at a slower rate, could potentially worsen the cramping by prolonging the discomfort. Choice D, increasing the flow of the enema solution, is also incorrect as it may intensify the cramping and cause more discomfort to the patient.
5. A nurse in a rural community center is providing education to a group of clients about first aid interventions for snake bites. Which of the following instructions should the nurse include in the teaching?
- A. Apply an ice pack directly to the affected area
- B. Immobilize the affected extremity with a splint
- C. Place a tourniquet above and below the affected area
- D. Elevate the affected extremity
Correct answer: B
Rationale: The correct answer is to immobilize the affected extremity with a splint. This helps to slow the spread of venom by limiting movement. Applying an ice pack directly to the affected area (Choice A) is not recommended for snake bites as it could exacerbate tissue damage. Placing a tourniquet above and below the affected area (Choice C) is also not advised as it can lead to further complications. Elevating the affected extremity (Choice D) is not recommended for snake bites; keeping it below the level of the heart is more appropriate to reduce venom spread.
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