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ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What intervention should the nurse take for a patient experiencing delayed wound healing?
- A. Monitor serum albumin levels
- B. Apply a dry dressing
- C. Administer antibiotics
- D. Change the wound dressing every 8 hours
Correct answer: A
Rationale: Monitoring serum albumin levels is crucial for patients with delayed wound healing. Low albumin levels indicate a lack of protein, which can impair the healing process and increase the risk of infection. By monitoring serum albumin levels, the nurse can assess the patient's nutritional status and make necessary interventions to promote wound healing. Applying a dry dressing (Choice B) may be appropriate depending on the wound characteristics, but it does not address the underlying cause of delayed healing. Administering antibiotics (Choice C) is not the first-line intervention for delayed wound healing unless there is an active infection present. Changing the wound dressing every 8 hours (Choice D) may lead to excessive disruption of the wound bed and hinder the healing process.
2. What are the signs and symptoms of Increased Intracranial Pressure (IICP)?
- A. Irritability, confusion, restlessness
- B. Fatigue and SOB
- C. Changes in pupillary response
- D. Elevated blood pressure
Correct answer: A
Rationale: The correct answer is A: Irritability, confusion, restlessness. These are common signs of Increased Intracranial Pressure (IICP) as they result from the increased pressure on brain tissue. Choices B, C, and D are incorrect. Fatigue and shortness of breath (SOB) are not typical symptoms of IICP. Changes in pupillary response can be seen in other conditions but are not specific to IICP. Elevated blood pressure is not a common sign of IICP.
3. 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.
4. What symptoms are expected in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized swelling and numbness
- C. Fever and infection
- D. Weakness and fatigue
Correct answer: A
Rationale: In a patient with compartment syndrome, the key symptoms include unrelieved pain, pallor, and pulselessness. These symptoms indicate reduced circulation in the affected compartment. Choice B is incorrect as localized swelling and numbness are not typically associated with compartment syndrome. Choice C is incorrect as fever and infection are not primary symptoms of compartment syndrome. Choice D is incorrect as weakness and fatigue are not typically seen in compartment syndrome.
5. What is the preferred electrical intervention for a patient with ventricular tachycardia with a pulse?
- A. Synchronized cardioversion
- B. Defibrillation
- C. Pacing
- D. Medication administration
Correct answer: A
Rationale: The correct answer is A: Synchronized cardioversion. In ventricular tachycardia with a pulse, synchronized cardioversion is the preferred electrical intervention. Synchronized cardioversion is used to treat tachyarrhythmias where there is a pulse present. Defibrillation (choice B) is used in emergencies for pulseless ventricular tachycardia or ventricular fibrillation. Pacing (choice C) is more suitable for bradycardias or certain conduction abnormalities. Medication administration (choice D) may be used in stable cases or as an adjunct to other treatments, but synchronized cardioversion is the primary intervention for ventricular tachycardia with a pulse.
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