ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. When caring for a patient with hypokalemia, what should the nurse monitor for?
- A. Monitor for muscle weakness
- B. Check for cardiac dysrhythmias
- C. Monitor for bradycardia
- D. Monitor for seizures
Correct answer: A
Rationale: Corrected Answer: Muscle weakness is a common sign of hypokalemia. The nurse should monitor for muscle weakness as potassium plays a crucial role in muscle function. Choices B, C, and D are incorrect because although hypokalemia can lead to cardiac dysrhythmias, bradycardia, and even seizures in severe cases, muscle weakness is a more common and specific sign directly related to potassium levels.
2. What causes atherosclerotic plaques to form in the body?
- A. Poor dietary habits
- B. Administration of statin medication
- C. Interruption of blood flow to the brain
- D. Injury to the endothelium of the coronary arteries
Correct answer: D
Rationale: Atherosclerotic plaques form in the body due to injury to the endothelium of the coronary arteries. When the endothelium is damaged, it triggers an inflammatory response that leads to the accumulation of fats, cholesterol, and other substances, forming plaques. These plaques can narrow the arteries, reducing blood flow and potentially leading to serious complications like heart attacks or strokes. Poor dietary habits (choice A) can contribute to the development of atherosclerosis by promoting the buildup of plaque-forming substances in the blood, but the direct cause is the injury to the endothelium. Administration of statin medication (choice B) is actually a treatment for high cholesterol and aims to reduce the risk of plaque formation. Interruption of blood flow to the brain (choice C) is more related to conditions like ischemic stroke rather than the primary cause of atherosclerotic plaque formation.
3. A healthcare provider is reviewing the history of a client who is requesting combination oral contraceptives. Which condition in the client's history is a contraindication?
- A. Hyperthyroidism.
- B. Thrombophlebitis.
- C. Diverticulosis.
- D. Hypocalcemia.
Correct answer: B
Rationale: Thrombophlebitis is a contraindication for the use of combination oral contraceptives due to the increased risk of thromboembolic events such as deep vein thrombosis and pulmonary embolism. Hyperthyroidism, diverticulosis, and hypocalcemia are not typically contraindications for using combination oral contraceptives, making choices A, C, and D incorrect.
4. A client has Diabetes Mellitus, Pulmonary Tuberculosis, and a new prescription for Isoniazid. Which of the following supplements should the nurse expect to administer to prevent an adverse effect of INH?
- A. Ascorbic acid
- B. Pyridoxine
- C. Folic acid
- D. Cyanocobalamin
Correct answer: B
Rationale: Pyridoxine is administered with Isoniazid to prevent peripheral neuropathy, a common adverse effect of the drug. It is essential to provide this supplement to the client to minimize the risk of developing this adverse effect. Ascorbic acid (Vitamin C) is not typically given to prevent INH adverse effects. Folic acid and Cyanocobalamin are not commonly administered with INH for this purpose.
5. You are to apply a transdermal patch of nitoglycerin to your client. The following are important guidelines to observe EXCEPT:
- A. Apply to hairless clean area of the skin not subject to much wrinkling
- B. Patches may be applied to distal part of the extremities like forearm
- C. Change application and site regularly to prevent irritation of the skin
- D. Wear gloves to avoid any medication on your hand
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
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