ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. A patient is admitted with chest pain, possible acute coronary syndrome. What should the nurse do first?
- A. Administer sublingual nitroglycerin
- B. Get IV access
- C. Obtain cardiac enzymes
- D. Auscultate heart sounds
Correct answer: A
Rationale: In a patient with chest pain, possible acute coronary syndrome, the nurse should administer sublingual nitroglycerin first. Nitroglycerin helps to vasodilate coronary arteries, improving blood flow to the heart, and reducing cardiac workload. This can alleviate chest pain and decrease cardiac tissue damage in acute coronary syndrome. Getting IV access, obtaining cardiac enzymes, and auscultating heart sounds are important steps in the assessment and management of acute coronary syndrome, but administering nitroglycerin to relieve chest pain and improve blood flow takes precedence as it directly addresses the patient's symptoms and aims to prevent further cardiac damage.
2. An RN is working through an ethical dilemma involving a patient on his unit. He has just identified the decision makers involved. Which step best describes the current stage the RN is working through?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
Correct answer: C
Rationale: The correct answer is C: Planning. In the planning phase of addressing an ethical dilemma, the goals of treatment are established, decision makers are identified, and all available options are reviewed. The assessment phase involves collecting data and information, the diagnosis phase involves analyzing the information to identify the problem, and the implementation phase involves carrying out the chosen plan of action. Therefore, in this scenario, where decision makers are being identified, the RN is in the planning stage.
3. What lab value should be prioritized for monitoring in a patient with HIV?
- A. CD4 T-cell count below 180 cells/mm3
- B. Hemoglobin levels
- C. Serum albumin levels
- D. White blood cell count
Correct answer: A
Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring CD4 T-cell count is crucial in patients with HIV as it reflects the status of their immune system. A CD4 count below 200 cells/mm3 is indicative of severe immunocompromise, necessitating close monitoring and potential intervention. Choices B, C, and D are less specific to HIV management and do not directly reflect the immune status in these patients. Hemoglobin levels are more relevant for assessing anemia, serum albumin levels for nutritional status, and white blood cell count for overall immune response, but none are as directly tied to HIV disease progression as the CD4 T-cell count.
4. According to __________ theory, children learn primarily through modeling.
- A. reinforcement
- B. operant conditioning
- C. social learning
- D. classical conditioning
Correct answer: C
Rationale: According to social learning theory, children primarily learn through modeling, observation, and imitation of others. This theory emphasizes the importance of cognitive processes in learning, as opposed to only focusing on direct reinforcement or punishment. Social learning theory was developed by psychologist Albert Bandura and is a key theory in the field of child development. Choice A, reinforcement, is incorrect as it refers to the process of strengthening a behavior through rewards or punishments. Choice B, operant conditioning, is also incorrect as it is a learning process that involves reinforcement and punishment to shape behavior. Choice D, classical conditioning, is not the correct answer as it involves learning through association between stimuli.
5. A client is prescribed an IM dose of penicillin. The client reports developing a rash after taking penicillin 3 years ago. What should the nurse do?
- A. Administer the prescribed dose.
- B. Withhold the medication.
- C. Ask the provider to change the prescription to an oral form.
- D. Administer an oral antihistamine at the same time.
Correct answer: B
Rationale: The nurse should withhold the medication and inform the provider of the client's previous rash after taking penicillin. This history suggests a potential allergic reaction to penicillin, which can range from mild to severe anaphylaxis. Notifying the provider allows for an alternative antibiotic to be prescribed, considering the client's allergy to penicillin. It is crucial to avoid administering a medication that could potentially lead to a severe allergic reaction in the client. Administering the prescribed dose (Choice A) could be harmful due to the potential for an allergic reaction. Changing the prescription to an oral form (Choice C) does not address the underlying issue of a potential penicillin allergy. Administering an oral antihistamine (Choice D) without consulting the provider may not be sufficient to prevent a severe allergic reaction.
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