ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What symptoms are associated with a thrombotic stroke?
- A. Gradual loss of function on one side of the body
- B. Sudden loss of consciousness
- C. Loss of motor function with nausea
- D. Severe headache and vomiting
Correct answer: A
Rationale: A thrombotic stroke presents with a gradual loss of function on one side of the body due to a clot blocking blood flow to the brain. This gradual onset distinguishes it from a hemorrhagic stroke with sudden symptoms like loss of consciousness (Choice B), and from other conditions like migraine, which may present with severe headache and vomiting (Choice D). Nausea (Choice C) is not typically a primary symptom associated with a thrombotic stroke.
2. What is the priority nursing intervention for a patient admitted with possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Obtain cardiac enzymes
- C. Get IV access
- D. Auscultate heart sounds
Correct answer: A
Rationale: The correct answer is to administer sublingual nitroglycerin. This intervention is a priority for a patient with possible acute coronary syndrome because nitroglycerin helps vasodilate coronary arteries, increase blood flow to the heart muscle, relieve chest pain, and reduce cardiac workload. Obtaining cardiac enzymes (choice B) is important for diagnosing myocardial infarction but is not the initial priority. Getting IV access (choice C) is essential for medication administration and fluid resuscitation but is not the priority over administering nitroglycerin. Auscultating heart sounds (choice D) is a routine assessment but does not address the immediate need to relieve chest pain and improve blood flow to the heart in acute coronary syndrome.
3. What is the priority nursing action when a patient with chest pain presents with possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Obtain IV access
- C. Check the patient's cardiac enzymes
- D. Administer aspirin
Correct answer: A
Rationale: The priority nursing action when a patient with chest pain presents with possible acute coronary syndrome is to administer sublingual nitroglycerin. Sublingual nitroglycerin helps dilate blood vessels, reducing cardiac workload, and improving blood supply to the heart muscle, thus relieving pain and enhancing blood flow to the heart. While obtaining IV access is important for administering medications and fluids, it is not the priority over addressing pain and improving blood flow. Checking the patient's cardiac enzymes is crucial for diagnosis and ongoing management but not the immediate priority when the patient is in pain. Administering aspirin is also a vital intervention in acute coronary syndrome, but in this scenario, it is not the priority action compared to providing immediate pain relief and enhancing blood flow to the heart.
4. What should be done when continuous bubbling is observed in the chest tube water seal chamber?
- A. Tighten the connections of the chest tube system
- B. Replace the chest tube system
- C. Clamp the chest tube
- D. Continue to monitor the chest tube
Correct answer: A
Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the appropriate action is to tighten the connections of the chest tube system. This may resolve an air leak that is causing the continuous bubbling. Option B, replacing the chest tube system, is not the initial step to take and is considered more invasive. Clamping the chest tube (option C) can lead to complications and should not be done unless instructed by a healthcare provider. Continuing to monitor the chest tube (option D) without taking any corrective action may delay necessary interventions.
5. 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.
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All ATI courses Coverage
- 30 days access
ATI RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All ATI courses Coverage
- 30 days access