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. Which lab value is a priority for a patient with HIV?
- A. CD4 T-cell count 180 cells/mm3
- B. Albumin levels below 3.5 g/dL
- C. Potassium levels below 3.5 mEq/L
- D. White blood cell count below 5000/mm3
Correct answer: A
Rationale: A CD4 T-cell count of less than 180 cells/mm3 is a priority for a patient with HIV because it indicates severe immunocompromise and an increased risk for opportunistic infections. Monitoring CD4 levels helps in assessing the immune status and guiding treatment decisions in patients with HIV. Albumin levels (choice B) are important for assessing nutritional status but are not a direct indicator of immune function in HIV patients. Potassium levels (choice C) and white blood cell count (choice D) are also important, but the CD4 T-cell count is specifically crucial for evaluating the immune function in individuals with HIV.
3. While administering a blood transfusion, a nurse suspects that the client is having an adverse reaction. Which of the following actions should the nurse take first?
- A. Maintain IV access
- B. Obtain the client's vital signs
- C. Contact the provider
- D. Stop the transfusion
Correct answer: D
Rationale: The correct first action for the nurse to take when suspecting an adverse reaction to a blood transfusion is to stop the transfusion immediately. Stopping the transfusion helps prevent further harm to the client. Maintaining IV access and obtaining vital signs are important steps but come after stopping the transfusion in this situation. Contacting the provider can be done after ensuring the client's safety by stopping the transfusion.
4. A patient who experienced an acute episode of gastritis should avoid which type of foods?
- A. Avoid foods high in potassium
- B. Avoid foods high in sodium
- C. Increase exercise
- D. Drink milk as a snack
Correct answer: A
Rationale: Patients who have experienced an acute episode of gastritis should avoid foods high in potassium. Potassium-rich foods can irritate the gastric lining, exacerbating gastritis symptoms. Therefore, choices B, C, and D are incorrect. Avoiding foods high in sodium is beneficial for other health conditions like hypertension, increasing exercise is generally good for overall health but not specifically for gastritis management, and drinking milk may provide temporary relief for some but is not a definitive recommendation for gastritis management.
5. 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.
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