ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What is the initial action for treating chest pain in acute coronary syndrome?
- A. Administer sublingual nitroglycerin
- B. Administer aspirin
- C. Check cardiac enzymes
- D. Obtain IV access
Correct answer: A
Rationale: The correct initial action for treating chest pain in acute coronary syndrome is to administer sublingual nitroglycerin. Nitroglycerin helps dilate blood vessels, reducing the workload on the heart and improving blood flow to the heart muscle. Administering aspirin can also be beneficial, but the priority is to address chest pain promptly. Checking cardiac enzymes and obtaining IV access are important steps but are not the initial actions needed to alleviate chest pain in acute coronary syndrome.
2. A nurse is planning care for a patient diagnosed with diabetes insipidus. What should be included in the care plan?
- A. Monitor serum albumin levels
- B. Restrict protein intake to 0.55-0.60 g/kg/day
- C. Encourage the patient to increase fluid intake
- D. Teach the patient to avoid alcohol
Correct answer: A
Rationale: The correct answer is to monitor serum albumin levels. In patients with diabetes insipidus, monitoring serum albumin levels is essential to assess for dehydration and nutritional deficits. Choices B, C, and D are not directly related to managing diabetes insipidus. Restricting protein intake, encouraging fluid intake, and teaching the patient to avoid alcohol are interventions that may be relevant for other medical conditions but are not specific to addressing the needs of a patient with diabetes insipidus.
3. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?
- A. Keep a padded tongue depressor near the bedside
- B. Place a pillow under the client's head during a seizure
- C. Administer diazepam intravenously at the onset of seizures
- D. Position the client on their side during a seizure
Correct answer: D
Rationale: The correct intervention for a client who has a seizure disorder is to position the client on their side during a seizure. This helps to prevent aspiration and ensures a patent airway. Keeping a padded tongue depressor near the bedside (Choice A) is not recommended as it can cause injury during a seizure. Placing a pillow under the client's head during a seizure (Choice B) is also not advised as it can obstruct the airway. Administering diazepam intravenously at the onset of seizures (Choice C) is not typically done at home without healthcare provider direction.
4. What is the first medication to give to a patient experiencing wheezing due to an allergic reaction?
- A. Albuterol via nebulizer
- B. Cromolyn 20 mg 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 due to its rapid action in opening airways. Cromolyn (Choice B) is used for prevention rather than acute treatment. Methylprednisolone (Choice C) and Aminophylline (Choice D) are not the first-line treatments for acute wheezing in allergic reactions.
5. A client who has burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?
- A. It is okay to not want to touch the burned areas of your body.
- B. Cosmetic surgery should be performed within the next year to be effective.
- C. Reconstructive surgery can completely restore your previous appearance.
- D. It could be helpful for you to attend a support group for people who have burn injuries.
Correct answer: D
Rationale: The nurse should encourage the client to attend a support group for individuals who have burn injuries. Support groups can provide emotional support, shared experiences, and coping strategies for accepting their altered appearance. Choice A is not the best response as it does not offer proactive support. Choice B is not appropriate as the timing of cosmetic surgery should be determined by healthcare providers, not immediate. Choice C is misleading as reconstructive surgery may improve appearance but may not completely restore the previous look.
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