a nurse is planning care for a group of postoperative clients which of the following interventions should the nurse identify as the priority

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is planning care for a group of postoperative clients. Which of the following interventions should the nurse identify as the priority?

A. Administer IV pain medication to a client who reports pain as a 6 on a scale of 0 to 10
B. Administer oxygen to a client who has an oxygen saturation of 91%
C. Instruct a client who is 1 hr postoperative about coughing and deep breathing exercises
D. Initiate an infusion of 0.9% sodium chloride for a client who has just had abdominal surgery

Correct answer: B

Rationale: The priority intervention is administering oxygen. Postoperatively, the client's oxygen saturation should be at or above 95%. Oxygen is essential for tissue perfusion and cellular oxygenation. While managing pain is important, oxygenation takes precedence. Instructing a client about coughing and deep breathing exercises is important for preventing respiratory complications but is not as urgent as addressing low oxygen saturation. Initiating an infusion of 0.9% sodium chloride is a routine postoperative intervention for fluid balance but is not the priority when oxygen saturation is low.

2. 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.

3. What is the first-line treatment for wheezing due to an allergic reaction?

A. Albuterol via nebulizer
B. Cromolyn via nebulizer
C. Methylprednisolone 100 mg IV
D. Aminophylline 500 mg 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 acts quickly to open the airways by relaxing the muscles in the air passages. Cromolyn (Choice B) is used for asthma prevention rather than acute wheezing. Methylprednisolone (Choice C) and Aminophylline (Choice D) are not the first-line treatments for acute wheezing in the setting of an allergic reaction.

4. A nurse misreads a glucose reading and administers insulin for a blood glucose of 210 instead of 120. What should the nurse monitor the patient for?

A. Monitor for hyperglycemia
B. Monitor for signs of hypoglycemia
C. Administer glucose IV
D. Document the incident

Correct answer: B

Rationale: The correct answer is B: Monitor for signs of hypoglycemia. The nurse should monitor the patient for hypoglycemia due to the administration of excess insulin. Administering insulin for a blood glucose level of 210 instead of 120 can lead to a rapid drop in blood sugar levels, causing hypoglycemia. Option A is incorrect as hyperglycemia is high blood sugar, which is unlikely in this scenario. Option C is incorrect as administering glucose IV would worsen the hypoglycemia. Option D is not the immediate priority; patient safety and monitoring for adverse effects take precedence.

5. A client scheduled for electromyography (EMG) will have small needle electrodes inserted into the muscles. What should the nurse include in the teaching?

A. You will receive a fixed dose of radioisotope 2 hours before the procedure.
B. Momentary flushing will occur at the beginning of the procedure.
C. You should inform your provider if you are claustrophobic.
D. You should expect insertion of small needle electrodes into the muscles.

Correct answer: D

Rationale: The correct answer is D. During an electromyography (EMG) procedure, small needle electrodes are inserted into the muscles to assess muscle weakness and nerve responses. Choices A, B, and C are incorrect because radioisotope is not used in EMG, flushing is not a typical occurrence, and claustrophobia is more relevant for imaging procedures like MRI or CT scans, not EMG.