ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What should be monitored for in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized redness and swelling
- C. Fever and infection
- D. Muscle weakness and fatigue
Correct answer: A
Rationale: Correct Answer: A. Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome that indicate inadequate blood flow to the affected area. These symptoms are crucial to monitor as they signify a medical emergency requiring immediate intervention. Choices B, C, and D are incorrect because they do not align with the typical manifestations of compartment syndrome. Localized redness and swelling may be present but are not the primary indicators. Fever and infection are also not specific to compartment syndrome, and muscle weakness and fatigue are not typically prominent symptoms of this condition.
2. What should the nurse do for a patient experiencing 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. This action helps relieve the cramping by slowing down the flow of the solution. Choice B, stopping the procedure and removing the tubing, is incorrect as it is too drastic and may not address the cramping. Choice C, continuing the enema at a slower rate, may exacerbate the cramping if the flow rate is still too high. Choice D, increasing the flow of the enema solution, would worsen the cramping and is not the appropriate intervention.
3. What is the first nursing action for a patient with chest pain and possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Increase fluids to prevent dehydration
- C. Obtain cardiac enzymes
- D. Get IV access and auscultate heart sounds
Correct answer: A
Rationale: Administering sublingual nitroglycerin is the priority nursing action for a patient with chest pain and possible acute coronary syndrome. Nitroglycerin helps dilate the blood vessels, improve blood flow to the heart, and reduce cardiac workload. This action aims to relieve chest pain promptly and prevent further cardiac tissue damage. Increasing fluids is not the initial priority for a patient with chest pain and possible acute coronary syndrome. Obtaining cardiac enzymes is important for diagnosis but is not the first action in managing acute symptoms. Getting IV access and auscultating heart sounds are important interventions, but they come after administering sublingual nitroglycerin in the management of acute coronary syndrome.
4. What should a healthcare provider teach a patient who has experienced an acute episode of gastritis?
- A. Avoid foods high in potassium
- B. Avoid foods high in sodium
- C. Increase exercise to reduce stress
- D. Drink milk as a snack
Correct answer: A
Rationale: The correct answer is A: Avoid foods high in potassium. During an acute episode of gastritis, it is advisable to avoid foods high in potassium as they can exacerbate symptoms. Potassium-rich foods may irritate the stomach lining, leading to increased discomfort. Choices B, C, and D are incorrect. Avoiding foods high in sodium is not specifically related to managing gastritis. Increasing exercise to reduce stress is a good general recommendation but not directly related to managing gastritis symptoms. Drinking milk as a snack is not recommended for gastritis as dairy products can sometimes worsen symptoms due to their fat content.
5. A patient with a new diagnosis of diabetes insipidus is planning care. What should be included in the plan of care?
- A. Avoid alcohol
- B. Increase exercise to reduce stress
- C. Increase fluid intake
- D. Restrict sodium intake
Correct answer: A
Rationale: The correct answer is to avoid alcohol. In diabetes insipidus, excessive urination leads to fluid loss, so it is essential to avoid alcohol which can exacerbate dehydration. Choice B is incorrect as increasing exercise may not directly impact diabetes insipidus. Choice C is also incorrect because although increasing fluid intake may seem intuitive, it is not the primary concern in managing diabetes insipidus. Choice D is not directly related to managing diabetes insipidus; sodium restriction is more relevant in conditions like hypertension or heart failure.
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