ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What should be the first medication given for wheezing due to an allergic reaction?
- A. Albuterol via nebulizer
- B. Cromolyn via nebulizer
- C. Methylprednisolone IV
- D. Aminophylline 500 mg IV
Correct answer: A
Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line medication for treating wheezing caused by an allergic reaction as it works as a bronchodilator, helping to relieve the symptoms of wheezing and shortness of breath quickly. Cromolyn (choice B) is used more for preventing asthma symptoms rather than for immediate relief. Methylprednisolone IV (choice C) and Aminophylline 500 mg IV (choice D) are not the first-line treatments for wheezing due to an allergic reaction.
2. A nurse is planning care for a patient diagnosed with diabetes insipidus. What should be included in the care plan?
- A. Monitor serum albumin levels
- B. Restrict protein intake to 0.55-0.60 g/kg/day
- C. Encourage the patient to increase fluid intake
- D. Teach the patient to avoid alcohol
Correct answer: A
Rationale: The correct answer is to monitor serum albumin levels. In patients with diabetes insipidus, monitoring serum albumin levels is essential to assess for dehydration and nutritional deficits. Choices B, C, and D are not directly related to managing diabetes insipidus. Restricting protein intake, encouraging fluid intake, and teaching the patient to avoid alcohol are interventions that may be relevant for other medical conditions but are not specific to addressing the needs of a patient with diabetes insipidus.
3. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?
- A. Decreased deep tendon reflexes
- B. Positive Chvostek's sign
- C. Hyperactive bowel sounds
- D. Dry mucous membranes
Correct answer: A
Rationale: Corrected deep tendon reflexes occur with hyponatremia. Other manifestations of hyponatremia include headache, confusion, lethargy, fatigue, seizures, and muscle weakness. Positive Chvostek's sign is associated with hypocalcemia, hyperactive bowel sounds are not typically related to hyponatremia, and dry mucous membranes are more commonly seen with dehydration.
4. A nurse administers insulin for a misread glucose level. What should the nurse monitor for?
- A. Monitor for hypoglycemia
- B. Monitor for hyperglycemia
- C. Monitor for hyperkalemia
- D. Document the incident
Correct answer: A
Rationale: When a nurse administers insulin for a misread glucose level, they should monitor for hypoglycemia. Insulin lowers blood sugar levels, so the patient may experience hypoglycemia if given insulin unnecessarily. Monitoring for hypoglycemia involves observing for symptoms such as shakiness, sweating, dizziness, confusion, and palpitations. Choices B and C are incorrect because administering insulin for a misread glucose level would lower blood sugar levels, resulting in hypoglycemia, not hyperglycemia or hyperkalemia. Choice D is not the immediate priority; the focus should be on patient safety and monitoring for potential adverse effects of the unnecessary insulin.
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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