ATI RN TEST BANK

ATI Capstone Medical Surgical Assessment 2 Quizlet

What are the signs and symptoms of compartment syndrome?

    A. Unrelieved pain, pallor, and pulselessness

    B. Localized redness and swelling

    C. Fever and infection

    D. Loss of sensation in the affected area

Correct Answer: A
Rationale: The signs and symptoms of compartment syndrome include unrelieved pain, pallor, and pulselessness. Unrelieved pain is a key characteristic, indicating tissue ischemia due to increased pressure within a closed anatomic space. Pallor results from compromised blood flow, and pulselessness indicates severe ischemia requiring immediate intervention. Choices B, C, and D are incorrect because localized redness and swelling, fever and infection, and loss of sensation are not specific signs of compartment syndrome. Therefore, the correct answer is A.

A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

  • A. Inspect the pin site every 4 hours
  • B. Monitor the client's skin under the halo vest
  • C. Ensure two personnel hold the halo device when repositioning the client
  • D. Apply powder to the client's skin under the vest to decrease itching

Correct Answer: B
Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.

What is the first intervention for a patient admitted with unstable angina?

  • A. Administer nitroglycerin
  • B. Obtain cardiac enzymes
  • C. Start IV fluids
  • D. Monitor for chest pain

Correct Answer: A
Rationale: The correct first intervention for a patient admitted with unstable angina is to administer nitroglycerin. Nitroglycerin helps to relieve chest pain by dilating blood vessels and increasing blood flow to the heart, thereby reducing cardiac workload. This intervention aims to alleviate symptoms and prevent further cardiac damage. Obtaining cardiac enzymes (Choice B) is important for diagnosing a myocardial infarction but is not the initial intervention for unstable angina. Starting IV fluids (Choice C) may be indicated in specific cases like hypovolemia but is not the primary intervention for unstable angina. Monitoring for chest pain (Choice D) is essential but taking action to alleviate the pain, like administering nitroglycerin, is the primary focus in the initial management of unstable angina.

What ECG changes should be monitored in a patient with hypokalemia?

  • A. Flattened T waves and prominent U waves
  • B. Elevated ST segments and wide QRS complexes
  • C. Tall T waves and flattened QRS complexes
  • D. Widened QRS complexes and decreased P wave amplitude

Correct Answer: A
Rationale: The correct answer is A: Flattened T waves and prominent U waves. In hypokalemia, there is a decrease in potassium levels, which can lead to ECG changes such as flattened T waves and prominent U waves. These changes are classic findings associated with hypokalemia. Choices B (Elevated ST segments and wide QRS complexes), C (Tall T waves and flattened QRS complexes), and D (Widened QRS complexes and decreased P wave amplitude) are all incorrect. Elevated ST segments and wide QRS complexes are not typically seen in hypokalemia. Tall T waves and flattened QRS complexes, as well as widened QRS complexes and decreased P wave amplitude, do not represent the typical ECG changes seen in hypokalemia.

What ECG changes are expected in a patient with hypokalemia?

  • A. Flattened T waves
  • B. Prominent U waves
  • C. Widened QRS complexes
  • D. Tall T waves

Correct Answer: A
Rationale: Flattened T waves are an early indicator of hypokalemia on an ECG. Hypokalemia primarily presents with flattened T waves, not prominent U waves, widened QRS complexes, or tall T waves. Prominent U waves are associated with hypokalemia only in severe cases. Widened QRS complexes are more indicative of hyperkalemia, while tall T waves are seen in hyperkalemia as well.

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