ATI RN
ATI Capstone Medical Surgical Assessment 2 Quizlet
1. What are the expected symptoms of a thrombotic stroke?
- A. Gradual loss of function on one side of the body
- B. Sudden loss of consciousness
- C. Severe headache and confusion
- D. Loss of sensation in the affected limb
Correct answer: A
Rationale: The correct answer is A: 'Gradual loss of function on one side of the body.' In a thrombotic stroke, a clot blocks a cerebral artery, leading to a gradual onset of symptoms such as weakness, numbness, or paralysis on one side of the body. Choice B, 'Sudden loss of consciousness,' is more characteristic of a hemorrhagic stroke. Choice C, 'Severe headache and confusion,' are often associated with subarachnoid hemorrhage rather than thrombotic stroke. Choice D, 'Loss of sensation in the affected limb,' is not a typical symptom pattern for a thrombotic stroke, which usually presents with motor deficits.
2. 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.
3. What symptoms are expected in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized swelling and numbness
- C. Fever and infection
- D. Weakness and fatigue
Correct answer: A
Rationale: In a patient with compartment syndrome, the key symptoms include unrelieved pain, pallor, and pulselessness. These symptoms indicate reduced circulation in the affected compartment. Choice B is incorrect as localized swelling and numbness are not typically associated with compartment syndrome. Choice C is incorrect as fever and infection are not primary symptoms of compartment syndrome. Choice D is incorrect as weakness and fatigue are not typically seen in compartment syndrome.
4. A patient with chronic kidney disease may require dietary restrictions. Which of the following diets should the healthcare provider prescribe?
- A. Low sodium diet
- B. Potassium restricted diet
- C. High phosphorus diet
- D. High protein diet
Correct answer: B
Rationale: Patients with chronic kidney disease often require a potassium-restricted diet to help manage their electrolyte levels. Excessive potassium intake can be harmful to individuals with compromised kidney function. While monitoring sodium intake is also important for these patients, a low sodium diet is not specifically indicated in the question. High phosphorus diet and high protein diet are not recommended for individuals with chronic kidney disease as they can further stress the kidneys and worsen the condition.
5. After a healthcare provider misreads a glucose level and administers insulin, what is the priority intervention?
- A. Monitor for hypoglycemia
- B. Administer glucose IV
- C. Document the incident
- D. Monitor for hyperglycemia
Correct answer: A
Rationale: The correct answer is to monitor for hypoglycemia. Administering insulin based on a misread glucose level can lead to hypoglycemia. Monitoring for hypoglycemia is crucial as it is a potential adverse effect of the insulin administration. Administering glucose IV (Choice B) is not the priority as there is no indication of hypoglycemia yet. Documenting the incident (Choice C) is important but not the immediate priority over patient safety. Monitoring for hyperglycemia (Choice D) is not the priority after administering insulin in response to a misread glucose level.
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