what is an escharotomy and when is it performed
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Nursing Elites

ATI RN

ATI Capstone Medical Surgical Assessment 1 Quizlet

1. What is an escharotomy and when is it performed?

Correct answer: A

Rationale: An escharotomy is a surgical incision made to release pressure in a part of the body that has a deep burn and excessive swelling. This procedure is crucial in preventing further damage due to restricted blood flow and compromised circulation. Choice B is incorrect because it describes debridement, which is the removal of dead tissue from wounds. Choice C is incorrect as it does not specifically address the purpose of relieving pressure in burn injuries. Choice D is incorrect as it describes a procedure more related to thoracentesis, which is the removal of excess fluid from the chest, typically the pleural space.

2. What is the first medication to administer to a patient experiencing wheezing due to an allergic reaction?

Correct answer: A

Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-choice medication for wheezing due to its fast-acting bronchodilatory effect, which helps in relieving the symptoms quickly. Choice B, Methylprednisolone 100 mg IV, is a corticosteroid used for its anti-inflammatory effects and would be beneficial in reducing inflammation in allergic reactions but is not the first-line treatment for wheezing. Choice C, Cromolyn 20 mg via nebulizer, is a mast cell stabilizer used to prevent asthma attacks but is not the immediate treatment for wheezing during an allergic reaction. Choice D, Aminophylline 500 mg IV, is a bronchodilator but is not typically the initial medication of choice for wheezing in an allergic reaction.

3. What are the signs and symptoms of Increased Intracranial Pressure (IICP)?

Correct answer: A

Rationale: The correct answer is A: Irritability, confusion, restlessness. These are common signs of Increased Intracranial Pressure (IICP) as they result from the increased pressure on brain tissue. Choices B, C, and D are incorrect. Fatigue and shortness of breath (SOB) are not typical symptoms of IICP. Changes in pupillary response can be seen in other conditions but are not specific to IICP. Elevated blood pressure is not a common sign of IICP.

4. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

Correct answer: B

Rationale: The priority intervention is administering oxygen. Postoperatively, the client's oxygen saturation should be at or above 95%. Oxygen is essential for tissue perfusion and cellular oxygenation. While managing pain is important, oxygenation takes precedence. Instructing a client about coughing and deep breathing exercises is important for preventing respiratory complications but is not as urgent as addressing low oxygen saturation. Initiating an infusion of 0.9% sodium chloride is a routine postoperative intervention for fluid balance but is not the priority when oxygen saturation is low.

5. What does continuous bubbling in the water seal chamber of a chest tube indicate?

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system. This bubbling occurs when air is escaping through the tube and entering the water seal chamber. Choice B, a blockage in the chest tube, is incorrect as continuous bubbling does not suggest a blockage. Choice C, normal chest tube function, is incorrect because continuous bubbling is not an expected finding in a properly functioning chest tube. Choice D, a malfunction in the drainage system, is incorrect as continuous bubbling specifically points towards an air leak, not a general malfunction.

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