ATI RN
ATI Capstone Medical Surgical Assessment 1 Quizlet
1. What are the early symptoms of compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized redness and swelling
- C. Fever and swelling
- D. Numbness and tingling
Correct answer: A
Rationale: The correct answer is A: 'Unrelieved pain, pallor, and pulselessness.' Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to reduced blood flow and potential tissue damage. Early symptoms include unrelieved pain (out of proportion to the injury), pallor (pale skin color), and pulselessness (decreased or absent pulses). Choices B, C, and D are incorrect as they do not represent the classic early symptoms of compartment syndrome.
2. A client with heart failure is prescribed furosemide 20 mg PO twice daily. Which of the following instructions should the nurse include during discharge teaching?
- A. Monitor for increased blood pressure
- B. Increase intake of high-potassium foods
- C. Expect an increase in swelling in the hands and feet
- D. Take the second dose at bedtime
Correct answer: B
Rationale: The correct answer is to instruct the client to increase their intake of high-potassium foods. Furosemide can lead to hypokalemia, a condition of low potassium levels in the blood. Increasing the consumption of high-potassium foods helps prevent this adverse effect. Monitoring for increased blood pressure (choice A) is not directly related to furosemide use. Expecting an increase in swelling (choice C) is incorrect as furosemide is a diuretic that helps reduce swelling. Taking the second dose at bedtime (choice D) is not necessary unless prescribed by the healthcare provider.
3. What are the expected findings in a patient with hypokalemia?
- A. Cardiac dysrhythmias
- B. Seizures and confusion
- C. Bradycardia
- D. Muscle weakness
Correct answer: A
Rationale: The correct answer is A: Cardiac dysrhythmias. Hypokalemia is commonly associated with cardiac dysrhythmias due to the role potassium plays in maintaining proper electrical conduction in the heart. Choices B, C, and D are incorrect. While hypokalemia can lead to muscle weakness, the most critical and life-threatening manifestation is cardiac dysrhythmias. Seizures and confusion are more commonly associated with other electrolyte imbalances, such as hyponatremia. Bradycardia is not a typical finding in hypokalemia, as it tends to cause tachycardia or other arrhythmias.
4. What is the initial nursing action for a patient with a chest tube found to have an air leak?
- A. Check the tube connections
- B. Replace the chest tube
- C. Remove and reinsert the chest tube
- D. Document the incident
Correct answer: A
Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.
5. A nurse misreads a glucose reading and administers insulin for a blood glucose of 210 instead of 120. What should the nurse monitor the patient for?
- A. Monitor for hyperglycemia
- B. Monitor for signs of hypoglycemia
- C. Administer glucose IV
- D. Document the incident
Correct answer: B
Rationale: The correct answer is B: Monitor for signs of hypoglycemia. The nurse should monitor the patient for hypoglycemia due to the administration of excess insulin. Administering insulin for a blood glucose level of 210 instead of 120 can lead to a rapid drop in blood sugar levels, causing hypoglycemia. Option A is incorrect as hyperglycemia is high blood sugar, which is unlikely in this scenario. Option C is incorrect as administering glucose IV would worsen the hypoglycemia. Option D is not the immediate priority; patient safety and monitoring for adverse effects take precedence.
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