ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. 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.
2. 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.
3. 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.
4. What are the adverse effects of radiation after a mastectomy?
- A. S3 heart sound, fatigue
- B. Pulselessness in the affected extremity
- C. SOB and JVD
- D. Localized pain, swelling, erythema
Correct answer: A
Rationale: The correct answer is A: S3 heart sound, fatigue. Radiation after a mastectomy can lead to fatigue and symptoms of heart failure, such as the presence of an S3 heart sound. Choices B, C, and D are incorrect. Pulselessness in the affected extremity would be more relevant to vascular complications, shortness of breath (SOB) and jugular venous distention (JVD) could indicate cardiac or respiratory issues unrelated to radiation, and localized pain, swelling, and erythema are more characteristic of a local inflammatory response rather than the systemic effects of radiation post-mastectomy.
5. What should the healthcare provider do if a patient presents with chest pain and possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Administer aspirin
- C. Obtain cardiac enzymes
- D. Get IV access and auscultate heart sounds
Correct answer: A
Rationale: Administering sublingual nitroglycerin is the priority action in the treatment of chest pain in acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improving blood flow to the heart and relieving chest pain. Aspirin can also be given to reduce clot formation, but nitroglycerin takes precedence in providing immediate relief. Obtaining cardiac enzymes and assessing heart sounds are important steps in the diagnostic process but do not address the immediate need to relieve chest pain and prevent cardiac tissue damage. Therefore, administering sublingual nitroglycerin is the most appropriate initial intervention for a patient presenting with chest pain and possible acute coronary syndrome.
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