ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What should a healthcare professional monitor in a patient receiving insulin who is at risk for hypoglycemia?
- A. Monitor blood glucose levels
- B. Monitor for respiratory distress
- C. Monitor for muscle weakness
- D. Monitor for hyperkalemia
Correct answer: A
Rationale: Monitoring blood glucose levels is crucial in patients receiving insulin who are at risk for hypoglycemia. Insulin can lower blood sugar levels, potentially leading to hypoglycemia, which can be harmful if not promptly recognized and managed. Checking blood glucose levels allows for early detection of low blood sugar levels, enabling timely interventions to prevent complications. Choices B, C, and D are incorrect as they do not directly relate to monitoring for hypoglycemia in patients receiving insulin.
2. What is the first nursing action for a patient with chest pain and possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Increase fluids to prevent dehydration
- C. Obtain cardiac enzymes
- D. Get IV access and auscultate heart sounds
Correct answer: A
Rationale: Administering sublingual nitroglycerin is the priority nursing action for a patient with chest pain and possible acute coronary syndrome. Nitroglycerin helps dilate the blood vessels, improve blood flow to the heart, and reduce cardiac workload. This action aims to relieve chest pain promptly and prevent further cardiac tissue damage. Increasing fluids is not the initial priority for a patient with chest pain and possible acute coronary syndrome. Obtaining cardiac enzymes is important for diagnosis but is not the first action in managing acute symptoms. Getting IV access and auscultating heart sounds are important interventions, but they come after administering sublingual nitroglycerin in the management of acute coronary syndrome.
3. After a healthcare provider misreads a glucose level and administers insulin, what is the priority intervention?
- A. Monitor for hypoglycemia
- B. Administer glucose IV
- C. Document the incident
- D. Monitor for hyperglycemia
Correct answer: A
Rationale: The correct answer is to monitor for hypoglycemia. Administering insulin based on a misread glucose level can lead to hypoglycemia. Monitoring for hypoglycemia is crucial as it is a potential adverse effect of the insulin administration. Administering glucose IV (Choice B) is not the priority as there is no indication of hypoglycemia yet. Documenting the incident (Choice C) is important but not the immediate priority over patient safety. Monitoring for hyperglycemia (Choice D) is not the priority after administering insulin in response to a misread glucose level.
4. What should a healthcare provider monitor for in a patient with hypokalemia?
- A. Monitor for muscle weakness
- B. Monitor for bradycardia
- C. Check deep tendon reflexes
- D. Monitor for hyperglycemia
Correct answer: A
Rationale: Corrected Rationale: Muscle weakness is a common symptom of hypokalemia and should be closely monitored in affected patients. Hypokalemia is a condition characterized by low potassium levels in the blood, which can lead to muscle weakness, cramps, and even paralysis. While bradycardia (slow heart rate) can be associated with severe hypokalemia, monitoring for muscle weakness is more specific to the condition. Checking deep tendon reflexes is not typically a primary monitoring parameter for hypokalemia. Monitoring for hyperglycemia is not directly related to hypokalemia, as hypokalemia is primarily associated with potassium levels in the blood.
5. A nurse is providing discharge teaching to a client following a heart transplant. Which of the following information should the nurse include in the teaching?
- A. Immunosuppressant medications need to be taken for up to 1 year
- B. Shortness of breath might be an indication of transplant rejection
- C. The surgical site will heal in 3 to 4 weeks after surgery
- D. Begin 45 minutes of moderate aerobic exercise per day following discharge
Correct answer: B
Rationale: The correct answer is B. Shortness of breath is an important sign of transplant rejection. Other manifestations of rejection include fatigue, edema, bradycardia, and hypotension. Choices A, C, and D are incorrect because: A) Immunosuppressant medications are typically required for life, not just up to 1 year. C) The surgical site healing time can vary and may take longer than 3 to 4 weeks. D) Starting a specific exercise regimen should be individualized and guided by healthcare providers; a general recommendation like 45 minutes of exercise per day may not be suitable for all heart transplant recipients.
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