ATI RN TEST BANK

ATI Capstone Medical Surgical Assessment 2 Quizlet

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.

What medication should be administered first for wheezing due to an allergic reaction?

  • A. Albuterol via nebulizer
  • B. Cromolyn via nebulizer
  • C. Methylprednisolone IV
  • D. Aminophylline IV

Correct Answer: A
Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction because it quickly opens the airways by relaxing the muscles around the airways. Cromolyn (choice B) is used more for prevention rather than immediate relief of symptoms. Methylprednisolone (choice C) and Aminophylline (choice D) are not the first-line treatments for acute wheezing due to an allergic reaction.

A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?

  • A. After stroking the lateral area of the foot, the client's toes contract and draw together
  • B. After hip flexion, the client is unable to extend their leg completely without pain
  • C. The client's voluntary movement is not coordinated
  • D. The client reports pain and stiffness when flexing their neck

Correct Answer: B
Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding suggests meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, Choice C refers to coordination deficits, and Choice D indicates neck pain and stiffness, which are not related to Kernig's sign.

What is the first-line treatment for a patient experiencing wheezing and coughing due to an allergic reaction?

  • A. Albuterol via nebulizer
  • B. Methylprednisolone 100 mg IV
  • C. Cromolyn 20 mg via nebulizer
  • D. Aminophylline 500 mg IV

Correct Answer: A
Rationale: The correct answer is A: Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction as it quickly opens the airways, providing rapid relief. Choice B, Methylprednisolone 100 mg IV, is a systemic corticosteroid that may be used in severe cases to reduce inflammation but is not the initial treatment for acute wheezing. Choice C, Cromolyn 20 mg via nebulizer, is a mast cell stabilizer that is more commonly used for prophylaxis rather than acute relief in allergic conditions. Choice D, Aminophylline 500 mg IV, is a bronchodilator that is less commonly used now due to its narrow therapeutic window and potential for toxicity, making it less preferred than Albuterol for initial treatment of wheezing.

When providing discharge teaching to a patient who underwent cataract surgery, what should the patient avoid?

  • A. Avoid NSAIDs
  • B. Avoid bright lights
  • C. Avoid alcohol
  • D. Avoid phosphorus-rich foods

Correct Answer: A
Rationale: The correct answer is to avoid NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding after cataract surgery due to their anticoagulant properties. Bright lights (choice B) are not contraindicated post-cataract surgery unless the patient experiences discomfort or sensitivity. Alcohol consumption (choice C) is generally not restricted after cataract surgery, but moderation is recommended. Phosphorus-rich foods (choice D) are not directly related to cataract surgery postoperative care.

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