ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What is an escharotomy and why is it performed?
- A. A surgical incision made to improve circulation in burn injuries
- B. A procedure to remove dead tissue from a wound
- C. A procedure to remove excess fluid from the lungs
- D. A procedure to relieve pain from burns
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 are the early symptoms of compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized redness and swelling
- C. Fever and swelling
- D. Numbness and tingling
Correct answer: A
Rationale: The correct answer is A: 'Unrelieved pain, pallor, and pulselessness.' Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to reduced blood flow and potential tissue damage. Early symptoms include unrelieved pain (out of proportion to the injury), pallor (pale skin color), and pulselessness (decreased or absent pulses). Choices B, C, and D are incorrect as they do not represent the classic early symptoms of compartment syndrome.
3. 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.
4. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?
- A. 1 packet of reconstituted dry onion soup
- B. 3 oz of lean cured ham
- C. 3 oz of chicken breast
- D. ½ cup of canned baked beans
Correct answer: C
Rationale: For a client with hypertension, a low sodium diet is recommended to help control blood pressure. Among the food choices provided, the best option is 3 oz of chicken breast. Chicken breast is lean protein with lower sodium content compared to other choices. It is a healthier option for managing hypertension. Reconstituted dry onion soup (Choice A) and canned baked beans (Choice D) typically contain higher amounts of sodium, which can be detrimental for blood pressure management. Lean cured ham (Choice B) also tends to have a higher sodium content, making it less suitable for a client with hypertension.
5. What is the first nursing action for a patient admitted with chest pain from acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Check the patient's urine output
- C. Administer IV fluids
- D. Obtain cardiac enzymes
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action for a patient admitted with chest pain from acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. Checking the patient's urine output (Choice B) is not the priority in this situation. Administering IV fluids (Choice C) may not be necessary unless indicated by the patient's condition. Obtaining cardiac enzymes (Choice D) is important but is not the initial action needed to address the patient's acute symptoms.
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