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. What are the expected manifestations in a patient experiencing a thrombotic stroke?
- A. Sudden numbness or loss of function on one side of the body
- B. Sudden loss of consciousness and seizure
- C. Gradual onset of difficulty speaking
- D. Loss of sensation in the affected limb
Correct answer: A
Rationale: The correct manifestation in a patient experiencing a thrombotic stroke is sudden numbness or loss of function on one side of the body. This is due to the blockage of a blood vessel by a clot, leading to a lack of blood flow to a specific part of the brain. Choices B, C, and D are incorrect. Sudden loss of consciousness and seizure are more commonly associated with hemorrhagic strokes. Gradual onset of difficulty speaking is often seen in ischemic strokes affecting language areas, not specifically in thrombotic strokes. Loss of sensation in the affected limb is more indicative of sensory nerve damage rather than the motor deficits seen in thrombotic strokes.
3. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should indicate to the nurse the need for immediate intervention?
- A. Axillary temperature 37.2°C (99°F)
- B. Apical pulse 100/min
- C. Respiratory rate 30/min
- D. Blood pressure 140/84 mm Hg
Correct answer: C
Rationale: The correct answer is C. The nurse should prioritize airway and breathing in a client with a traumatic brain injury. An increased respiratory rate may indicate CO2 retention, which could lead to increased intracranial pressure. Choice A, axillary temperature 37.2°C (99°F), is within normal range and does not indicate an immediate need for intervention. Choice B, apical pulse 100/min, is slightly elevated but not as critical as respiratory distress in this scenario. Choice D, blood pressure 140/84 mm Hg, is also within normal limits and does not require immediate intervention compared to the respiratory rate.
4. What is the priority action for a patient experiencing chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Obtain IV access
- C. Check the patient's cardiac enzymes
- D. Administer aspirin
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. Nitroglycerin helps relieve chest pain by dilating blood vessels and improving blood flow to the heart, which is crucial in managing acute coronary syndrome. While obtaining IV access and checking cardiac enzymes are important steps in the assessment and management of acute coronary syndrome, administering nitroglycerin takes precedence to alleviate symptoms and reduce cardiac tissue damage. Administering aspirin is also essential in the treatment of acute coronary syndrome, but it is not the immediate priority in this scenario.
5. What are the expected ECG findings in hypokalemia?
- A. Flattened T waves
- B. Prominent U waves
- C. Elevated ST segments
- D. Wide QRS complex
Correct answer: A
Rationale: Flattened T waves are the classic ECG finding in hypokalemia. Hypokalemia primarily affects the repolarization phase of the cardiac action potential, leading to T wave abnormalities. While prominent U waves are typically associated with hypokalemia as well, flattened T waves are the most specific and sensitive ECG abnormality seen in hypokalemia. Elevated ST segments and wide QRS complexes are not typically seen in hypokalemia and are more indicative of other electrolyte imbalances or cardiac conditions.
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