ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. 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.
2. A patient is admitted with chest pain, possible acute coronary syndrome. What should the nurse do first?
- A. Administer sublingual nitroglycerin
- B. Get IV access
- C. Obtain cardiac enzymes
- D. Auscultate heart sounds
Correct answer: A
Rationale: In a patient with chest pain, possible acute coronary syndrome, the nurse should administer sublingual nitroglycerin first. Nitroglycerin helps to vasodilate coronary arteries, improving blood flow to the heart, and reducing cardiac workload. This can alleviate chest pain and decrease cardiac tissue damage in acute coronary syndrome. Getting IV access, obtaining cardiac enzymes, and auscultating heart sounds are important steps in the assessment and management of acute coronary syndrome, but administering nitroglycerin to relieve chest pain and improve blood flow takes precedence as it directly addresses the patient's symptoms and aims to prevent further cardiac damage.
3. What is the first nursing action for a patient with chest pain and possible acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Increase fluids to prevent dehydration
- C. Obtain cardiac enzymes
- D. Get IV access and auscultate heart sounds
Correct answer: A
Rationale: Administering sublingual nitroglycerin is the priority nursing action for a patient with chest pain and possible acute coronary syndrome. Nitroglycerin helps dilate the blood vessels, improve blood flow to the heart, and reduce cardiac workload. This action aims to relieve chest pain promptly and prevent further cardiac tissue damage. Increasing fluids is not the initial priority for a patient with chest pain and possible acute coronary syndrome. Obtaining cardiac enzymes is important for diagnosis but is not the first action in managing acute symptoms. Getting IV access and auscultating heart sounds are important interventions, but they come after administering sublingual nitroglycerin in the management of acute coronary syndrome.
4. 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.
5. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider?
- A. Breath sounds
- B. Temperature
- C. Blood pressure
- D. Creatine kinase
Correct answer: A
Rationale: The correct answer is A: Breath sounds. When caring for a client with unstable angina, changes in breath sounds could indicate left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. Reporting any abnormalities in breath sounds promptly to the provider is crucial to prevent further complications. Choices B, C, and D are not directly related to the immediate management of unstable angina. Temperature, blood pressure, and creatine kinase levels are important parameters to monitor but are not the priority in this situation.
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