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ATI Capstone Medical Surgical Assessment 1 Quizlet
1. 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.
2. What is the priority intervention for a patient with unstable angina?
- A. Administer nitroglycerin
- B. Establish IV access
- C. Auscultate heart sounds
- D. Administer aspirin
Correct answer: A
Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with unstable angina as it helps dilate blood vessels, improve blood flow to the heart, relieve chest pain, and prevent further cardiac damage. Establishing IV access (choice B) may be important but is not the priority over administering nitroglycerin in this scenario. Auscultating heart sounds (choice C) and administering aspirin (choice D) are also important aspects of managing unstable angina, but they are not the immediate priority intervention when a patient is experiencing chest pain.
3. A patient reports abdominal cramping during an enema administration. What action should the nurse take?
- A. Increase the flow of the enema
- B. Lower the height of the enema solution container
- C. Stop the enema procedure
- D. Remove the enema tubing
Correct answer: B
Rationale: When a patient experiences abdominal cramping during an enema administration, the nurse should lower the height of the enema solution container. Lowering the container helps to relieve cramping by slowing the flow of the solution, making it more comfortable for the patient. Increasing the flow (Choice A) would exacerbate the cramping. Stopping the procedure (Choice C) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (Choice D) is not the initial action indicated for cramping; adjusting the height is the more appropriate intervention.
4. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?
- A. Keep a padded tongue depressor near the bedside
- B. Place a pillow under the client's head during a seizure
- C. Administer diazepam intravenously at the onset of seizures
- D. Position the client on their side during a seizure
Correct answer: D
Rationale: The correct intervention for a client who has a seizure disorder is to position the client on their side during a seizure. This helps to prevent aspiration and ensures a patent airway. Keeping a padded tongue depressor near the bedside (Choice A) is not recommended as it can cause injury during a seizure. Placing a pillow under the client's head during a seizure (Choice B) is also not advised as it can obstruct the airway. Administering diazepam intravenously at the onset of seizures (Choice C) is not typically done at home without healthcare provider direction.
5. 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.
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