a nurse is caring for a client who has dehydration the client has a peripheral iv and a prescription for an infusion of 09 sodium chloride 1000 ml wit

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ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is caring for a client who has dehydration. The client has a peripheral IV and a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?

A. Teach the client to report findings of IV extravasation
B. Evaluate the patency of the IV
C. Consult with the pharmacist about the prescription
D. Verify the prescription with the provider

Correct answer: D

Rationale: The nurse's priority action should be to verify the prescription with the provider. This is crucial to prevent injury from fluid volume overload and rapid potassium infusion. Verifying the prescription ensures that the correct solution, rate, and additives are ordered according to the client's condition. While evaluating the patency of the IV is important, verifying the prescription takes precedence to ensure patient safety. Consulting with the pharmacist can be beneficial, but confirming the prescription with the provider is the immediate priority. Teaching the client about IV extravasation is important but is not the first action the nurse should take in this scenario.

2. What are the characteristics of a thrombotic stroke?

A. Gradual onset over minutes to hours
B. Numbness on one side of the body
C. Associated with a loss of consciousness
D. Associated with seizures and convulsions

Correct answer: A

Rationale: The correct answer is A. Thrombotic strokes typically have a gradual onset over minutes to hours as they result from a clot obstructing blood flow. Choice B, numbness on one side of the body, is more commonly associated with an ischemic stroke rather than specifically a thrombotic stroke. Choice C, loss of consciousness, is not a defining characteristic of a thrombotic stroke. Choice D, seizures and convulsions, are more commonly seen in hemorrhagic strokes rather than thrombotic strokes.

3. What should the healthcare provider do first when a patient is admitted with chest pain and 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 priority intervention when a patient presents with chest pain and suspected acute coronary syndrome. Nitroglycerin helps dilate blood vessels, improve blood flow to the heart, and relieve chest pain. It is crucial to address the pain and potential ischemia promptly to prevent further cardiac tissue damage. Getting IV access, auscultating heart sounds, and obtaining cardiac enzymes are important assessments and interventions, but administering nitroglycerin takes precedence in managing acute coronary syndrome.

4. What is the correct response when a patient receiving an enema reports abdominal cramping?

A. Lower the height of the enema container
B. Stop the enema procedure
C. Remove the enema tubing
D. Continue the enema at a slower rate

Correct answer: A

Rationale: The correct response when a patient receiving an enema reports abdominal cramping is to lower the height of the enema container. Lowering the height reduces the flow rate, which can help relieve cramping. Stopping the procedure (choice B) may not be necessary if adjusting the height resolves the issue. Removing the enema tubing (choice C) is not the initial step to take when addressing abdominal cramping during an enema. Continuing the enema at a slower rate (choice D) might not be as effective as lowering the height of the container to alleviate cramping.

5. What ECG changes should be monitored in a patient with hypokalemia?

A. Flattened T waves and prominent U waves
B. Elevated ST segments and wide QRS complexes
C. Tall T waves and flattened QRS complexes
D. Widened QRS complexes and decreased P wave amplitude

Correct answer: A

Rationale: The correct answer is A: Flattened T waves and prominent U waves. In hypokalemia, there is a decrease in potassium levels, which can lead to ECG changes such as flattened T waves and prominent U waves. These changes are classic findings associated with hypokalemia. Choices B (Elevated ST segments and wide QRS complexes), C (Tall T waves and flattened QRS complexes), and D (Widened QRS complexes and decreased P wave amplitude) are all incorrect. Elevated ST segments and wide QRS complexes are not typically seen in hypokalemia. Tall T waves and flattened QRS complexes, as well as widened QRS complexes and decreased P wave amplitude, do not represent the typical ECG changes seen in hypokalemia.