ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What is the first action a healthcare provider should take for a patient with possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Get IV access
- C. Auscultate heart sounds
- D. Obtain cardiac enzymes
Correct answer: A
Rationale: Administering sublingual nitroglycerin is the initial priority action for a patient with possible acute coronary syndrome. Nitroglycerin helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart muscle. This helps in relieving symptoms and preventing further damage to the heart. Establishing IV access, auscultating heart sounds, and obtaining cardiac enzymes are important steps in the assessment and management of acute coronary syndrome but are not the first actions to be taken. IV access may be needed for administering medications or fluids, auscultating heart sounds helps in assessing the heart's function, and obtaining cardiac enzymes aids in diagnosing a heart attack.
2. A patient with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate?
- A. Encourage the patient to ignore the voices.
- B. Provide a structured and safe environment.
- C. Engage the patient in a debate about the reality of the voices.
- D. Ask the patient to describe the content of the hallucinations.
Correct answer: D
Rationale: The most appropriate nursing intervention when a patient with schizophrenia is experiencing auditory hallucinations is to ask the patient to describe the content of the hallucinations. This intervention helps assess the risk associated with the hallucinations and provides valuable insight into the patient's condition, aiding in developing an effective care plan. Encouraging the patient to ignore the voices (Choice A) may not address the underlying issues or risks associated with the hallucinations. Providing a structured and safe environment (Choice B) is important but does not directly address the hallucinations. Engaging the patient in a debate about the reality of the voices (Choice C) may worsen the situation by invalidating the patient's experiences.
3. A nurse is preparing to administer filgrastim to a client undergoing chemotherapy. What is the primary purpose of this medication?
- A. Increase white blood cell production.
- B. Reduce the risk of infection.
- C. Enhance red blood cell production.
- D. Control chemotherapy-induced nausea and vomiting.
Correct answer: A
Rationale: Filgrastim is primarily used to increase white blood cell production in clients undergoing chemotherapy.
4. Which instrument is used for auscultation?
- A. Percussion hammer
- B. Audiometer
- C. Stethoscope
- D. Sphygmomanometer
Correct answer: C
Rationale: Auscultation involves listening to internal sounds in the body, such as heart and lung sounds. The instrument used for auscultation is a stethoscope, which allows healthcare providers to listen to these sounds. The percussion hammer is used to elicit sounds on the body, the audiometer is used to measure hearing ability, and the sphygmomanometer is used to measure blood pressure. Therefore, the correct answer is 'Stethoscope.'
5. A school nurse is meeting with a high school student who mentions that she is frustrated with her repeated outbreaks of cold sores. The student states that she tried an over-the-counter topical cream but that it failed to produce an appreciable improvement. The nurse should recognize that this student used what medication?
- A. Ganciclovir
- B. Valacyclovir (Valtrex)
- C. Famciclovir (Famvir)
- D. Docosanol (Abreva)
Correct answer: D
Rationale: The correct answer is D: Docosanol (Abreva). Docosanol is an over-the-counter topical cream commonly used to treat cold sores caused by the herpes simplex virus. It works by inhibiting viral fusion to host cell membranes, reducing the spread of the virus. Ganciclovir (Choice A) is an antiviral medication used for the treatment of cytomegalovirus infections. Valacyclovir (Choice B) and Famciclovir (Choice C) are prescription antiviral medications used to treat herpes simplex virus infections but are not typically available over-the-counter like Docosanol.
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