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Adult Medical Surgical ATI
1. Which of the following statements is true about ischemic colitis?
- A. Typically requires colonic resection
- B. Affects the watershed areas of the colon, namely, the splenic flexure, right colon, and rectum
- C. Is only seen in the elderly
- D. Requires colonoscopic intervention
Correct answer: B
Rationale: Ischemic colitis most often results from low-flow states associated with hypotension or poor perfusion. As a result, the vascular watershed areas of the colon, including the splenic flexure, right colon, and rectum, are at highest risk of ischemic injury. Therefore, option B is correct as it accurately identifies the areas commonly affected by ischemic colitis.
2. A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?
- A. 90-degree angle
- B. 60-degree angle
- C. 75-degree angle
- D. 45-degree angle
Correct answer: A
Rationale: The correct answer is A: 90-degree angle. The ventrogluteal site is preferred for intramuscular injections because it is away from major nerves and blood vessels. Administering the injection at a 90-degree angle ensures that the medication reaches deep into the muscle tissue, allowing for proper absorption of the drug. Choice B, 60-degree angle, is incorrect as it is not the recommended angle for the ventrogluteal site. Choice C, 75-degree angle, and Choice D, 45-degree angle, are also incorrect as they are not the appropriate angles for administering an intramuscular injection using the ventrogluteal site.
3. The nurse is caring for a patient who has just received a cancer diagnosis. The patient is crying. The nurse recognizes this patient is operating on what level of Maslow's hierarchy of needs?
- A. Self-esteem
- B. Love and belonging
- C. Safety
- D. Self-actualization
Correct answer: C
Rationale: In Maslow's hierarchy of needs, safety needs come after physiological needs. When a patient is crying after receiving a cancer diagnosis, they may be feeling a lack of security and safety. This indicates that the patient is operating on the level of safety needs in Maslow's hierarchy. Choice A, self-esteem, focuses on confidence and respect, which is not the immediate concern when receiving a cancer diagnosis. Choice B, love and belonging, pertains to relationships and social connections, which are important but not the primary focus in this situation. Choice D, self-actualization, involves personal growth and fulfilling one's potential, which is a higher-level need compared to safety needs, making it less likely for a patient to be operating at this level when distressed by a cancer diagnosis.
4. What is the priority nursing intervention for a patient with chest pain?
- A. Administer nitroglycerin
- B. Assess pain level
- C. Monitor vital signs
- D. Provide oxygen therapy
Correct answer: A
Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with chest pain because it helps relieve chest pain by dilating coronary arteries, improving blood flow to the heart muscle. Assessing pain level, monitoring vital signs, and providing oxygen therapy are important interventions as well, but administering nitroglycerin takes precedence in addressing the immediate symptom of chest pain and potential cardiac ischemia.
5. When planning to perform a sterile dressing change for a client, which of the following actions should a healthcare professional take?
- A. Wear sterile gloves to remove the old dressing.
- B. Cleanse the wound with an antiseptic solution.
- C. Use clean gloves to apply the new dressing.
- D. Open sterile supplies before donning sterile gloves.
Correct answer: D
Rationale: Opening sterile supplies before donning sterile gloves is a critical step in maintaining the sterility of the supplies during a dressing change procedure. By doing so, the healthcare professional ensures that they do not touch non-sterile surfaces with their hands once sterile gloves are worn, reducing the risk of introducing pathogens to the wound and minimizing the potential for contamination.
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