ATI RN
ATI Capstone Adult Medical Surgical Assessment 1
1. A client scheduled for electromyography (EMG) will have small needle electrodes inserted into the muscles. What should the nurse include in the teaching?
- A. You will receive a fixed dose of radioisotope 2 hours before the procedure.
- B. Momentary flushing will occur at the beginning of the procedure.
- C. You should inform your provider if you are claustrophobic.
- D. You should expect insertion of small needle electrodes into the muscles.
Correct answer: D
Rationale: The correct answer is D. During an electromyography (EMG) procedure, small needle electrodes are inserted into the muscles to assess muscle weakness and nerve responses. Choices A, B, and C are incorrect because radioisotope is not used in EMG, flushing is not a typical occurrence, and claustrophobia is more relevant for imaging procedures like MRI or CT scans, not EMG.
2. What should be monitored in a patient receiving insulin who is at risk for hypoglycemia?
- A. Monitor blood glucose levels
- B. Monitor for respiratory distress
- C. Monitor for hypertension
- D. Monitor for hyperkalemia
Correct answer: A
Rationale: Corrected Question: In a patient receiving insulin who is at risk for hypoglycemia, monitoring blood glucose levels is crucial. This helps in preventing and identifying hypoglycemia promptly. Choice B, monitoring for respiratory distress, is not directly related to hypoglycemia caused by insulin. Choice C, monitoring for hypertension, is not typically associated with hypoglycemia. Choice D, monitoring for hyperkalemia, is not a common concern in patients receiving insulin who are at risk for hypoglycemia.
3. A nurse misreads a blood glucose level and administers excess insulin. What should the nurse monitor for?
- A. Monitor for hyperglycemia
- B. Monitor for hypoglycemia
- C. Administer glucose IV
- D. Monitor for increased thirst
Correct answer: B
Rationale: The correct answer is to monitor for hypoglycemia. Excess insulin can lead to low blood glucose levels, causing hypoglycemia. Symptoms of hypoglycemia include sweating, trembling, dizziness, confusion, and in severe cases, loss of consciousness. Options A, C, and D are incorrect because administering excess insulin would not lead to hyperglycemia or increased thirst, and administering glucose IV would exacerbate the issue by further lowering blood glucose levels.
4. What signs indicate increased intracranial pressure (IICP)?
- A. Restlessness, irritability, and confusion
- B. Sudden onset of seizures
- C. Bradycardia and altered pupil response
- D. Loss of consciousness
Correct answer: A
Rationale: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These symptoms occur due to the brain's increased pressure within the skull. Sudden onset of seizures (Choice B) is not typically associated with increased intracranial pressure. Bradycardia and altered pupil response (Choice C) are signs of advanced or worsening IICP. Loss of consciousness (Choice D) is a late sign of increased intracranial pressure.
5. A patient with ventricular tachycardia and a pulse needs electrical intervention. What is the appropriate action?
- A. Defibrillation
- B. Synchronized cardioversion
- C. Pacing
- D. Medication administration
Correct answer: B
Rationale: For a patient with ventricular tachycardia and a pulse, the appropriate action is synchronized cardioversion. Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Pacing is typically used for bradycardias. Medication administration may be considered in stable ventricular tachycardia cases but electrical intervention is preferred for immediate correction in this scenario.
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