ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What is a characteristic sign of hypokalemia on an ECG?
- A. Flattened T waves
- B. ST elevation
- C. Prominent U waves
- D. Widened QRS complex
Correct answer: A
Rationale: Flattened T waves are a characteristic sign of hypokalemia on an ECG. When potassium levels are low, it can lead to changes in the ECG, such as T wave flattening. This alteration is important to recognize as it indicates potential electrolyte imbalances. ST elevation (Choice B) is not typically associated with hypokalemia but can be seen in conditions like myocardial infarction. Prominent U waves (Choice C) are associated with hypokalemia, but flattened T waves are more specific. Widened QRS complex (Choice D) is not a typical ECG finding in hypokalemia but can be seen in conditions like hyperkalemia.
2. What ECG changes are seen in hypokalemia?
- A. Flattened T waves on the ECG
- B. Elevated ST segments on the ECG
- C. Widened QRS complex
- D. Prominent U waves on the ECG
Correct answer: A
Rationale: The correct answer is A: Flattened T waves on the ECG. Flattened T waves are an early indicator of hypokalemia on an ECG. Choice B, Elevated ST segments, is not typically seen in hypokalemia but can be a sign of myocardial infarction. Choice C, Widened QRS complex, is more commonly associated with hyperkalemia. Choice D, Prominent U waves, is typically associated with hypokalemia, but flattened T waves are considered a more specific and early sign.
3. What is the preferred treatment for a patient with unstable angina admitted with chest pain?
- A. Administer sublingual nitroglycerin
- B. Establish IV access
- C. Auscultate heart sounds
- D. Obtain cardiac enzymes
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. Nitroglycerin helps vasodilate coronary arteries, improving blood flow to the heart, relieving chest pain, and preventing cardiac tissue damage. Establishing IV access (choice B) is important but not the preferred initial treatment for unstable angina with chest pain. Auscultating heart sounds (choice C) and obtaining cardiac enzymes (choice D) are relevant assessments but do not address the immediate symptomatic relief needed for a patient with unstable angina and chest pain.
4. What is the priority action when the nurse administers insulin for a misread blood glucose reading?
- A. Monitor for signs of hypoglycemia
- B. Monitor for hyperglycemia
- C. Administer glucose IV
- D. Document the incident
Correct answer: A
Rationale: The priority action when the nurse administers insulin for a misread blood glucose reading is to monitor for signs of hypoglycemia. Insulin administration based on a misread blood glucose could lead to hypoglycemia due to an unnecessary dose. Monitoring for signs of hypoglycemia is crucial for prompt intervention if blood glucose levels drop dangerously low. Option B, monitoring for hyperglycemia, is incorrect in this situation as the concern is over-treatment with insulin causing hypoglycemia. Option C, administering glucose IV, is only necessary if hypoglycemia occurs. Option D, documenting the incident, is important for reporting and learning purposes but is not the immediate priority when the focus is on patient safety and preventing complications.
5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse identify as a possible complication of TPN administration?
- A. Pitting edema of bilateral lower extremities
- B. Hypoactive bowel sounds in all four quadrants
- C. Weight is the same as the day before
- D. Bilateral posterior lung sounds are diminished
Correct answer: A
Rationale: The correct answer is A: Pitting edema of bilateral lower extremities. Pitting edema can indicate fluid overload, which is a potential complication of TPN administration. Choice B, hypoactive bowel sounds, is more indicative of a gastrointestinal issue rather than a complication of TPN. Choice C, weight remaining the same, is expected to remain stable with proper TPN administration. Choice D, diminished lung sounds, is not directly related to TPN administration and is more suggestive of a respiratory issue.
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