ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What intervention should the nurse take for a patient experiencing delayed wound healing?
- A. Monitor serum albumin levels
- B. Apply a dry dressing
- C. Administer antibiotics
- D. Change the wound dressing every 8 hours
Correct answer: A
Rationale: Monitoring serum albumin levels is crucial for patients with delayed wound healing. Low albumin levels indicate a lack of protein, which can impair the healing process and increase the risk of infection. By monitoring serum albumin levels, the nurse can assess the patient's nutritional status and make necessary interventions to promote wound healing. Applying a dry dressing (Choice B) may be appropriate depending on the wound characteristics, but it does not address the underlying cause of delayed healing. Administering antibiotics (Choice C) is not the first-line intervention for delayed wound healing unless there is an active infection present. Changing the wound dressing every 8 hours (Choice D) may lead to excessive disruption of the wound bed and hinder the healing process.
2. What is the initial nursing action for a patient with a chest tube found to have an air leak?
- A. Check the tube connections
- B. Replace the chest tube
- C. Remove and reinsert the chest tube
- D. Document the incident
Correct answer: A
Rationale: When a patient with a chest tube is found to have an air leak, the priority action for the nurse is to check the tube connections. This step helps identify the source of the air leak, which can be caused by loose or disconnected tube connections. Once the source of the leak is identified and addressed, further interventions may be necessary. Replacing or removing and reinserting the chest tube should not be the initial response unless there are specific indications for these actions. Documenting the incident is important but comes after addressing the immediate concern of the air leak.
3. What should the nurse monitor for in a patient with hypokalemia?
- A. Monitor for muscle weakness
- B. Check deep tendon reflexes (DTRs)
- C. Monitor for seizures
- D. Monitor for bradycardia
Correct answer: A
Rationale: The correct answer is to monitor for muscle weakness in a patient with hypokalemia. Hypokalemia, which is low potassium levels, can lead to muscle weakness due to its effects on neuromuscular function. Checking deep tendon reflexes (Choice B) is not typically associated with hypokalemia. Seizures (Choice C) are more commonly associated with low calcium levels rather than low potassium levels. Bradycardia (Choice D) is a symptom of hyperkalemia (high potassium levels) rather than hypokalemia.
4. What medication should be administered first for wheezing due to an allergic reaction?
- A. Albuterol via nebulizer
- B. Cromolyn via nebulizer
- C. Methylprednisolone IV
- D. Aminophylline IV
Correct answer: A
Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction because it quickly opens the airways by relaxing the muscles around the airways. Cromolyn (choice B) is used more for prevention rather than immediate relief of symptoms. Methylprednisolone (choice C) and Aminophylline (choice D) are not the first-line treatments for acute wheezing due to an allergic reaction.
5. What ECG changes are expected in a patient with hypokalemia?
- A. Flattened T waves
- B. Prominent U waves
- C. Widened QRS complexes
- D. Tall T waves
Correct answer: A
Rationale: Flattened T waves are an early indicator of hypokalemia on an ECG. Hypokalemia primarily presents with flattened T waves, not prominent U waves, widened QRS complexes, or tall T waves. Prominent U waves are associated with hypokalemia only in severe cases. Widened QRS complexes are more indicative of hyperkalemia, while tall T waves are seen in hyperkalemia as well.
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