ATI RN
ATI Capstone Medical Surgical Assessment 1 Quizlet
1. What should the nurse do when continuous bubbling is seen in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Clamp the chest tube
- C. Replace the chest tube
- D. Continue monitoring the chest tube
Correct answer: A
Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the nurse should tighten the connections of the chest tube system. This action can often resolve an air leak causing the continuous bubbling. Clamping the chest tube or replacing it would not address the underlying issue of an air leak and may lead to complications. Continuing to monitor the chest tube without taking corrective action may result in the deterioration of the patient's condition.
2. What are the manifestations of osteomyelitis?
- A. Localized pain, swelling, erythema
- B. Elevated white blood cells
- C. Elevated calcium levels
- D. Low potassium levels
Correct answer: A
Rationale: Osteomyelitis often manifests as localized pain, swelling, and erythema due to infection in the bone. These symptoms are characteristic of inflammation and infection in the bone tissue. Elevated white blood cells (Choice B) may be present as part of the body's immune response to the infection but are not specific manifestations of osteomyelitis. Elevated calcium levels (Choice C) and low potassium levels (Choice D) are not typically associated with osteomyelitis.
3. A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend?
- A. Low potassium diet
- B. High fiber diet
- C. Low fat diet
- D. Low sodium diet
Correct answer: C
Rationale: The correct answer is C: Low fat diet. A low-fat diet is recommended for clients with chronic cholecystitis to reduce episodes of biliary colic. High-fat foods can trigger symptoms by causing the gallbladder to contract, leading to pain. Choice A, a low potassium diet, is not specifically indicated for chronic cholecystitis. Choice B, a high fiber diet, though generally healthy, may worsen symptoms in some individuals with cholecystitis due to the increased intestinal gas production. Choice D, a low sodium diet, is not directly related to the management of chronic cholecystitis.
4. A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and is receiving 3% sodium chloride via continuous IV. Which of the following laboratory findings should the nurse identify as an indication that the SIADH is resolving?
- A. Urine specific gravity 1.020
- B. Sodium 119 mEq/L
- C. BUN 8 mg/dL
- D. Calcium 8.7 mg/dL
Correct answer: A
Rationale: A urine specific gravity of 1.020 is within the expected reference range and indicates that the kidneys are appropriately concentrating urine, which is a sign that the syndrome of inappropriate antidiuretic hormone (SIADH) is resolving. A low sodium level (choice B) is associated with SIADH, so a sodium level of 119 mEq/L is not indicative of resolution. BUN (choice C) and calcium levels (choice D) are typically not directly related to SIADH resolution.
5. 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.
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