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. 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.
3. What is the first medication to administer for a patient experiencing wheezing due to an allergic reaction?
- A. Albuterol 3 ml via nebulizer
- B. Cromolyn 20 mg via nebulizer
- C. Methylprednisolone 100 mg IV
- D. Aminophylline 500 mg IV
Correct answer: A
Rationale: The correct answer is A, Albuterol 3 ml via nebulizer. Albuterol is the first-line medication for wheezing due to its rapid bronchodilatory effects. Choice B, Cromolyn, is used more for preventing allergic reactions rather than acute relief of wheezing. Choice C, Methylprednisolone, is a steroid used for its anti-inflammatory effects and is not the initial choice for acute relief of wheezing. Choice D, Aminophylline, is a bronchodilator but is not the first-line treatment for wheezing due to allergic reactions.
4. What should be monitored in a patient receiving insulin who is at risk for hypoglycemia?
- A. Monitor blood glucose levels
- B. Monitor for respiratory distress
- C. Monitor for hypertension
- D. Monitor for hyperkalemia
Correct answer: A
Rationale: Corrected Question: In a patient receiving insulin who is at risk for hypoglycemia, monitoring blood glucose levels is crucial. This helps in preventing and identifying hypoglycemia promptly. Choice B, monitoring for respiratory distress, is not directly related to hypoglycemia caused by insulin. Choice C, monitoring for hypertension, is not typically associated with hypoglycemia. Choice D, monitoring for hyperkalemia, is not a common concern in patients receiving insulin who are at risk for hypoglycemia.
5. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?
- A. Lie on your left side.
- B. Lie on your right side.
- C. Increase your fluid intake.
- D. Decrease your fluid intake.
Correct answer: B
Rationale: After a liver biopsy, the nurse should instruct the client to lie on the right side. This position helps apply pressure to the biopsy site, promoting hemostasis and reducing the risk of bleeding. Lying on the left side may not provide adequate pressure to the site. Increasing fluid intake is generally beneficial to prevent dehydration and aid in the recovery process, whereas decreasing fluid intake could lead to dehydration and possible complications. Therefore, the correct instruction is to lie on the right side.
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