ATI Capstone Adult Medical Surgical Assessment 1

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A nurse in an emergency department is caring for a client who has sustained multiple injuries. The nurse observes the client's thorax moving inward during inspiration and outward during expiration. The nurse should suspect which of the following injuries?

  • A. Flail chest
  • B. Hemothorax
  • C. Pulmonary contusion
  • D. Pneumothorax
Correct Answer: A

Rationale: The correct answer is A: Flail chest. Flail chest results from multiple rib fractures, causing paradoxical chest movement where the injured part moves inward during inspiration and outward during expiration, interfering with ventilation. Choice B, Hemothorax, involves blood in the pleural cavity and does not typically cause paradoxical chest movement. Choice C, Pulmonary contusion, is a bruise to the lung tissue and does not present with paradoxical chest movement. Choice D, Pneumothorax, is the presence of air in the pleural space, leading to lung collapse, but it does not demonstrate paradoxical chest movement like in flail chest.

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While administering a blood transfusion, a nurse suspects that the client is having an adverse reaction. Which of the following actions should the nurse take first?

  • A. Maintain IV access
  • B. Obtain the client's vital signs
  • C. Contact the provider
  • D. Stop the transfusion
Correct Answer: D

Rationale: The correct first action for the nurse to take when suspecting an adverse reaction to a blood transfusion is to stop the transfusion immediately. Stopping the transfusion helps prevent further harm to the client. Maintaining IV access and obtaining vital signs are important steps but come after stopping the transfusion in this situation. Contacting the provider can be done after ensuring the client's safety by stopping the transfusion.

A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50, PaCO2 29 mm Hg, and HCO3- 25 mEq/L. The nurse should recognize that the client has which of the following acid-base imbalances?

  • A. Respiratory acidosis
  • B. Respiratory alkalosis
  • C. Metabolic acidosis
  • D. Metabolic alkalosis
Correct Answer: B

Rationale: The correct answer is B: Respiratory alkalosis. In this scenario, the client is experiencing respiratory alkalosis due to hyperventilation. Hyperventilation leads to excessive loss of carbon dioxide, causing a decrease in hydrogen ion concentration and an increase in pH levels. Choices A, C, and D are incorrect. Respiratory acidosis is characterized by high PaCO2 and low pH. Metabolic acidosis is associated with low HCO3- levels and low pH. Metabolic alkalosis is marked by high HCO3- levels and high pH. In this case, the ABG results indicate respiratory alkalosis.

A patient is receiving discharge instructions for GERD. Which of the following statements by the patient demonstrates an understanding of the teaching?

  • A. I should take my medication with orange juice.
  • B. Having a bedtime snack will prevent heartburn.
  • C. I will lie down after meals.
  • D. I will limit activities that require bending at the waist.
Correct Answer: D

Rationale: The correct answer is D. Patients with GERD should avoid activities that increase intra-abdominal pressure, such as bending at the waist, as this can lead to reflux. Choice A is incorrect because medications for GERD are usually taken with water, not citrus juices. Choice B is incorrect as having a bedtime snack can worsen GERD symptoms. Choice C is incorrect because lying down after meals can also exacerbate reflux due to the effects of gravity.

A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?

  • A. Place several pillows behind the client's head
  • B. Place the client in a Sim's position
  • C. Keep the client's neck in a midline position
  • D. Maintain flexion of the client's hips at a 90° angle
Correct Answer: C

Rationale: Keeping the client's neck in a midline position is crucial for managing increased intracranial pressure. This position helps optimize blood flow and minimizes the risk of further increasing ICP. Placing several pillows behind the client's head (Choice A) may inadvertently elevate the head, potentially worsening ICP. Placing the client in a Sim's position (Choice B) or maintaining flexion of the client's hips at a 90° angle (Choice D) are not directly related to managing increased ICP.

A nurse is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the nurse plan to administer?

  • A. Lidocaine
  • B. Adenosine
  • C. Atropine
  • D. Verapamil
Correct Answer: C

Rationale: The correct answer is C: Atropine. The client's presentation of bradycardia, diaphoresis, and chest pain indicates reduced cardiac output, requiring intervention to increase the heart rate. Atropine is used to treat bradycardia by blocking cardiac muscarinic receptors, thus inhibiting the parasympathetic nervous system. Lidocaine (Choice A) is used for ventricular arrhythmias, not bradycardia. Adenosine (Choice B) is used for supraventricular tachycardia, not bradycardia. Verapamil (Choice D) is a calcium channel blocker used for certain arrhythmias and hypertension, but not for increasing heart rate in bradycardia.

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