ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. When caring for a patient with hypokalemia, what should the nurse monitor for?
- A. Monitor for muscle weakness
- B. Check for cardiac dysrhythmias
- C. Monitor for bradycardia
- D. Monitor for seizures
Correct answer: A
Rationale: Corrected Answer: Muscle weakness is a common sign of hypokalemia. The nurse should monitor for muscle weakness as potassium plays a crucial role in muscle function. Choices B, C, and D are incorrect because although hypokalemia can lead to cardiac dysrhythmias, bradycardia, and even seizures in severe cases, muscle weakness is a more common and specific sign directly related to potassium levels.
2. What is the priority intervention when a patient experiences abdominal cramping during enema administration?
- A. Lower the height of the enema solution container
- B. Stop the procedure and remove the tubing
- C. Continue the enema at a slower rate
- D. Increase the flow of the enema solution
Correct answer: A
Rationale: The correct answer is to lower the height of the enema solution container. This action can help relieve abdominal cramping by slowing the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is not the priority as adjusting the height of the container can often resolve the issue without needing to stop the procedure completely. Choice C, continuing the enema at a slower rate, may not address the immediate discomfort experienced by the patient. Choice D, increasing the flow of the enema solution, can exacerbate the cramping and should be avoided.
3. A patient with hypokalemia is being monitored. What should the nurse assess for?
- A. Muscle weakness
- B. Flattened T waves
- C. Checking deep tendon reflexes
- D. Seizures
Correct answer: A
Rationale: Corrected Question: A patient with hypokalemia is being monitored. What should the nurse assess for? Corrected Choice A: Muscle weakness Corrected Choice B: Flattened T waves Corrected Choice C: Checking deep tendon reflexes Corrected Choice D: Seizures Rationale: Hypokalemia is associated with muscle weakness due to the effect of low potassium levels on muscle function. Flattened T waves on an ECG are characteristic of hypokalemia but are not a direct assessment for the patient's condition. Checking deep tendon reflexes and seizures are not primary symptoms associated with hypokalemia, making them less relevant for monitoring a patient with this electrolyte imbalance.
4. What is the priority intervention for a patient with unstable angina?
- A. Administer nitroglycerin
- B. Establish IV access
- C. Auscultate heart sounds
- D. Administer aspirin
Correct answer: A
Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with unstable angina as it helps dilate blood vessels, improve blood flow to the heart, relieve chest pain, and prevent further cardiac damage. Establishing IV access (choice B) may be important but is not the priority over administering nitroglycerin in this scenario. Auscultating heart sounds (choice C) and administering aspirin (choice D) are also important aspects of managing unstable angina, but they are not the immediate priority intervention when a patient is experiencing chest pain.
5. What are the expected symptoms in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized swelling and redness
- C. Fever and swelling
- D. Weakness and fatigue
Correct answer: A
Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. These symptoms are classic signs of compartment syndrome, which is a serious condition characterized by reduced circulation in a closed muscle compartment. The pain is typically severe and disproportionate to the injury, and if left untreated, it can lead to tissue damage and loss of function. Choices B, C, and D are incorrect because they do not represent the hallmark symptoms of compartment syndrome. Localized swelling and redness may be present but are not specific to this condition. Fever and swelling are more indicative of inflammation or infection, while weakness and fatigue are nonspecific and do not typically occur in isolation in compartment syndrome.
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