what is an escharotomy and why is it performed
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Nursing Elites

ATI RN

ATI Capstone Adult Medical Surgical Assessment 2

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

Correct answer: A

Rationale: An escharotomy is a surgical procedure involving an incision through the eschar (dead tissue) to relieve pressure in burn injuries. It is performed to improve circulation to the affected area, prevent further damage, and restore blood flow. Choice B is incorrect because an escharotomy is not primarily focused on removing dead tissue but rather on relieving pressure. Choice C is incorrect as it describes a procedure related to pulmonary issues, not burn injuries. Choice D is incorrect because while pain relief may be a result of an escharotomy, it is not the primary purpose of the procedure.

2. What is the initial action for treating chest pain in acute coronary syndrome?

Correct answer: A

Rationale: The correct initial action for treating chest pain in acute coronary syndrome is to administer sublingual nitroglycerin. Nitroglycerin helps dilate blood vessels, reducing the workload on the heart and improving blood flow to the heart muscle. Administering aspirin can also be beneficial, but the priority is to address chest pain promptly. Checking cardiac enzymes and obtaining IV access are important steps but are not the initial actions needed to alleviate chest pain in acute coronary syndrome.

3. What should be monitored in a patient with diabetes insipidus?

Correct answer: A

Rationale: In a patient with diabetes insipidus, monitoring urine specific gravity for values below 1.005 is crucial. Low urine specific gravity indicates excessive water loss, a key characteristic of diabetes insipidus. Monitoring for increased thirst (choice B) may be a symptom presented by the patient, but it does not directly reflect the condition's severity. Monitoring serum albumin levels (choice C) is not typically associated with diabetes insipidus. Monitoring blood pressure closely (choice D) is not a primary concern in diabetes insipidus unless severe dehydration leads to hypotension.

4. A patient reports abdominal cramping during an enema administration. What action should the nurse take?

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.

5. How does hyponatremia place the patient at risk?

Correct answer: C

Rationale: Hyponatremia places the patient at risk for cardiac dysrhythmias. While hyponatremia can lead to seizures due to cerebral edema caused by fluid imbalance, the most immediate and life-threatening risk is cardiac dysrhythmias. Low sodium levels can disrupt the heart's electrical activity, potentially leading to fatal arrhythmias. Although fatigue and muscle weakness are symptoms of hyponatremia, cardiac dysrhythmias pose the most critical concern as they can have severe consequences.

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