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. What should be done when continuous bubbling is observed in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Replace the chest tube system
- C. Clamp the chest tube
- D. Continue to monitor the chest tube
Correct answer: A
Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the appropriate action is to tighten the connections of the chest tube system. This may resolve an air leak that is causing the continuous bubbling. Option B, replacing the chest tube system, is not the initial step to take and is considered more invasive. Clamping the chest tube (option C) can lead to complications and should not be done unless instructed by a healthcare provider. Continuing to monitor the chest tube (option D) without taking any corrective action may delay necessary interventions.
3. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider?
- A. Breath sounds
- B. Temperature
- C. Blood pressure
- D. Creatine kinase
Correct answer: A
Rationale: The correct answer is A: Breath sounds. When caring for a client with unstable angina, changes in breath sounds could indicate left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. Reporting any abnormalities in breath sounds promptly to the provider is crucial to prevent further complications. Choices B, C, and D are not directly related to the immediate management of unstable angina. Temperature, blood pressure, and creatine kinase levels are important parameters to monitor but are not the priority in this situation.
4. What is the priority lab value for monitoring a patient with HIV?
- A. CD4 T-cell count below 180 cells/mm3
- B. Serum albumin levels
- C. White blood cell count
- D. Hemoglobin levels
Correct answer: A
Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it serves as a key indicator of immune function. A count below 180 cells/mm3 indicates severe immunocompromise and an increased risk of opportunistic infections. Choice B, serum albumin levels, though important for assessing nutritional status, is not the priority lab value for HIV monitoring. Choice C, white blood cell count, is a nonspecific measure of immune function and may not accurately reflect the status of the immune system in HIV patients. Choice D, hemoglobin levels, are essential for evaluating anemia but are not the primary lab value for monitoring HIV.
5. A client has a Transient Ischemic Attack (TIA). What should the nurse teach?
- A. Avoid eating within 3 hours of bedtime
- B. Consume liquids between meals
- C. Eat large meals to increase caloric intake
- D. Avoid liquids to prevent aspiration
Correct answer: A
Rationale: The correct answer is A: Avoid eating within 3 hours of bedtime. For a client with a Transient Ischemic Attack (TIA), it is crucial to avoid eating within 3 hours of bedtime to reduce reflux that can worsen symptoms. Choice B is incorrect because consuming liquids between meals is not specifically related to managing TIA. Choice C is incorrect as eating large meals may not be recommended, especially if the client needs to watch their caloric intake. Choice D is incorrect because avoiding liquids entirely can lead to dehydration and is not a standard recommendation for TIA management.
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