ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What teaching should be provided to a patient following surgical removal of a cataract?
- A. Avoid NSAIDs
- B. Wear dark glasses while outdoors
- C. Creamy white drainage is normal
- D. Reduce phosphorus intake to 700 mg/day
Correct answer: A
Rationale: The correct teaching to provide to a patient following surgical removal of a cataract is to avoid NSAIDs. NSAIDs can increase the risk of bleeding at the surgical site, so it is important to steer clear of them. Choice B, wearing dark glasses while outdoors, may be recommended post-surgery to protect the eyes from bright light, but it is not the priority teaching in this case. Choice C, stating that creamy white drainage is normal, is not accurate as drainage from the eye should be monitored and reported. Choice D, reducing phosphorus intake to 700 mg/day, is unrelated to post-cataract surgery care and is not a necessary teaching point.
2. A patient has been diagnosed with a thrombotic stroke. What are the expected manifestations?
- A. Gradual loss of function on one side of the body
- B. Sudden loss of consciousness
- C. Seizures and confusion
- D. Loss of sensation in the affected limb
Correct answer: A
Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' Thrombotic strokes lead to slow and progressive symptoms as a result of decreased blood flow to a specific area of the brain. Choices B, C, and D are incorrect because sudden loss of consciousness, seizures, confusion, and loss of sensation in the affected limb are not typical manifestations of a thrombotic stroke.
3. What teaching should be provided to a patient following cataract surgery?
- A. Avoid NSAIDs
- B. Wear dark glasses outdoors
- C. Creamy white drainage is normal
- D. Avoid alcohol
Correct answer: A
Rationale: The correct teaching to provide to a patient following cataract surgery is to avoid NSAIDs. NSAIDs should be avoided post-cataract surgery to reduce the risk of bleeding. Choice B, wearing dark glasses outdoors, is important to protect the eyes from bright light but is not directly related to medication use. Choice C, stating that creamy white drainage is normal, is incorrect as drainage should be monitored for excessive redness, swelling, or pain. Choice D, avoiding alcohol, is not a direct post-cataract surgery teaching point related to medication use.
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. The nurse misread a patient's glucose as 210 mg/dL instead of 120 mg/dL and administered the insulin dose for a reading over 200 mg/dL. What is the priority action?
- A. Administer glucose IV
- B. Monitor for hyperglycemia
- C. Monitor for hypoglycemia
- D. Document the incident
Correct answer: C
Rationale: The priority action is to monitor the patient for signs of hypoglycemia as the nurse administered excess insulin due to misreading the glucose level. Administering glucose IV (Choice A) is not the immediate priority when dealing with hypoglycemia. Monitoring for hyperglycemia (Choice B) is not the correct action as the insulin was administered for a higher glucose reading. Documenting the incident (Choice D) is important but not the priority when the patient's safety is at risk due to possible hypoglycemia.
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