what is the purpose of an escharotomy
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Nursing Elites

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ATI Capstone Medical Surgical Assessment 2 Quizlet

1. What is the purpose of an escharotomy?

Correct answer: A

Rationale: An escharotomy is performed to relieve pressure and improve circulation in areas affected by deep burns. This procedure helps prevent complications such as compartment syndrome by releasing the constricting eschar. Choice B is incorrect because while pain relief may be a secondary outcome of the procedure, the primary purpose is to address pressure and circulation issues. Choice C is incorrect as an escharotomy specifically focuses on releasing pressure, not removing necrotic tissue. Choice D is incorrect as the primary goal of an escharotomy is not to prevent infection but rather to address the immediate issues related to deep burn injuries.

2. A client is being taught about fecal occult blood testing (FOBT) for colorectal cancer screening. Which of the following statements should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D because the nurse should advise the client to avoid corticosteroids, anti-inflammatory medications, and vitamin C before fecal occult blood testing to prevent false-positive results. Choice A is incorrect as stool samples for FOBT are usually collected using a kit at home. Choice B is incorrect because stimulant laxatives are not typically used before FOBT. Choice C is incorrect as guidelines recommend starting colorectal cancer screening at the age of 50, not 40.

3. A patient reports abdominal cramping after enema administration. What action should the nurse take to relieve the discomfort?

Correct answer: A

Rationale: The correct action to relieve abdominal cramping after enema administration is to lower the height of the solution container. This adjustment slows down the flow rate of the enema solution, which can help reduce discomfort by decreasing the pressure on the patient's abdomen. Increasing the flow of the enema solution (Choice B) would exacerbate the cramping by introducing more solution quickly. Removing the enema tubing (Choice C) is not necessary to address the cramping, and stopping the procedure (Choice D) may not be needed if adjusting the height of the solution container can resolve the issue.

4. What is the priority intervention for a patient with unstable angina?

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 lab value should be prioritized for monitoring in a patient with HIV?

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring CD4 T-cell count is crucial in patients with HIV as it reflects the status of their immune system. A CD4 count below 200 cells/mm3 is indicative of severe immunocompromise, necessitating close monitoring and potential intervention. Choices B, C, and D are less specific to HIV management and do not directly reflect the immune status in these patients. Hemoglobin levels are more relevant for assessing anemia, serum albumin levels for nutritional status, and white blood cell count for overall immune response, but none are as directly tied to HIV disease progression as the CD4 T-cell count.

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