ATI RN TEST BANK

ATI Capstone Adult Medical Surgical Assessment 2

What ECG changes are associated with hyperkalemia?

    A. Flattened T waves

    B. ST depression

    C. Prominent U waves

    D. Elevated ST segments

Correct Answer: B
Rationale: Hyperkalemia is known to cause ST depression on an ECG. Flattened T waves are more commonly seen in hypokalemia. Prominent U waves are associated with hypokalemia rather than hyperkalemia. Elevated ST segments are not typical findings in hyperkalemia.

What should a healthcare provider monitor for in a patient with HIV and a CD4 T-cell count below 180 cells/mm3?

  • A. Monitor for signs of infection
  • B. Monitor for anemia
  • C. Monitor for dehydration
  • D. Monitor for bleeding

Correct Answer: A
Rationale: A CD4 T-cell count below 180 cells/mm3 indicates severe immunocompromise in a patient with HIV. Monitoring for signs of infection is crucial because the patient is at high risk of developing opportunistic infections. Anemia (choice B), dehydration (choice C), and bleeding (choice D) are not directly associated with a low CD4 T-cell count in patients with HIV.

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.

What should the nurse monitor for in a patient with hypokalemia?

  • A. Monitor for muscle weakness
  • B. Check deep tendon reflexes (DTRs)
  • C. Monitor for seizures
  • D. Monitor for bradycardia

Correct Answer: A
Rationale: The correct answer is to monitor for muscle weakness in a patient with hypokalemia. Hypokalemia, which is low potassium levels, can lead to muscle weakness due to its effects on neuromuscular function. Checking deep tendon reflexes (Choice B) is not typically associated with hypokalemia. Seizures (Choice C) are more commonly associated with low calcium levels rather than low potassium levels. Bradycardia (Choice D) is a symptom of hyperkalemia (high potassium levels) rather than hypokalemia.

A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider?

  • A. Breath sounds
  • B. Temperature
  • C. Blood pressure
  • D. Creatine kinase

Correct Answer: A
Rationale: The correct answer is A: Breath sounds. When caring for a client with unstable angina, changes in breath sounds could indicate left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. Reporting any abnormalities in breath sounds promptly to the provider is crucial to prevent further complications. Choices B, C, and D are not directly related to the immediate management of unstable angina. Temperature, blood pressure, and creatine kinase levels are important parameters to monitor but are not the priority in this situation.

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