ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What should be taught to a patient following cataract surgery?
- A. Avoid NSAIDs
- B. Wear dark glasses when outdoors
- C. Report green or yellow drainage immediately
- D. Itching is normal unless accompanied by pain and nausea
Correct answer: A
Rationale: The correct answer is to avoid NSAIDs after cataract surgery to reduce the risk of bleeding. Choice B, wearing dark glasses when outdoors, is generally recommended after cataract surgery to protect the eyes from bright sunlight, but it is not the most critical instruction. Choice C, reporting green or yellow drainage immediately, is important to monitor for signs of infection, but it is not specific to cataract surgery. Choice D, itching is normal unless accompanied by pain and nausea, is not the most crucial advice post-cataract surgery. Therefore, the key instruction is to avoid NSAIDs to minimize bleeding risk.
2. When planning care for a patient with diabetes insipidus, what should the nurse include in the plan?
- A. Monitor serum albumin levels
- B. Avoid alcohol
- C. Teach the patient to increase fluids
- D. Increase exercise to reduce stress
Correct answer: B
Rationale: The correct answer is B: 'Avoid alcohol.' Alcohol consumption can exacerbate dehydration in patients with diabetes insipidus, so it is essential to advise them to avoid alcohol. Monitoring serum albumin levels (choice A) is not directly related to managing diabetes insipidus. Teaching the patient to increase fluids (choice C) is not recommended as it can worsen the condition by further diluting the urine. Increasing exercise to reduce stress (choice D) is not a primary intervention for managing diabetes insipidus.
3. If a nurse misread a glucose reading as 210 mg/dL instead of 120 mg/dL and administered insulin, what should the nurse monitor for?
- A. Monitor for hypoglycemia
- B. Monitor for hyperglycemia
- C. Administer glucose IV
- D. Document the incident
Correct answer: A
Rationale: The correct answer is to monitor for hypoglycemia. In this scenario, the nurse administered insulin based on an incorrect glucose reading, which could lead to a drop in blood sugar levels. Monitoring for hypoglycemia is crucial to prevent any adverse effects on the patient's health. Choice B, monitoring for hyperglycemia, is incorrect as the administration of insulin can lead to low blood sugar levels, not high. Choice C, administering glucose IV, is not the immediate action needed as monitoring for hypoglycemia comes first. Choice D, documenting the incident, is important but not the initial priority when patient safety is at risk.
4. What should a healthcare professional monitor for in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized redness and swelling
- C. Fever and signs of infection
- D. Loss of deep tendon reflexes
Correct answer: A
Rationale: Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome. In this condition, increased pressure within a muscle compartment impairs blood flow, leading to severe pain that is not relieved by usual measures, pallor from decreased blood flow, and pulselessness due to compromised circulation. These signs indicate a medical emergency requiring immediate intervention. Localized redness and swelling (Choice B) are more characteristic of inflammation or infection rather than compartment syndrome. Fever and signs of infection (Choice C) are not typical manifestations of compartment syndrome. Loss of deep tendon reflexes (Choice D) is associated with conditions affecting the nervous system, not compartment syndrome.
5. What is the first intervention for a patient admitted with unstable angina?
- A. Administer nitroglycerin
- B. Obtain cardiac enzymes
- C. Start IV fluids
- D. Monitor for chest pain
Correct answer: A
Rationale: The correct first intervention for a patient admitted with unstable angina is to administer nitroglycerin. Nitroglycerin helps to relieve chest pain by dilating blood vessels and increasing blood flow to the heart, thereby reducing cardiac workload. This intervention aims to alleviate symptoms and prevent further cardiac damage. Obtaining cardiac enzymes (Choice B) is important for diagnosing a myocardial infarction but is not the initial intervention for unstable angina. Starting IV fluids (Choice C) may be indicated in specific cases like hypovolemia but is not the primary intervention for unstable angina. Monitoring for chest pain (Choice D) is essential but taking action to alleviate the pain, like administering nitroglycerin, is the primary focus in the initial management of unstable angina.
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