ATI RN
ATI Capstone Adult Medical Surgical Assessment 2
1. What should a healthcare provider monitor for in a patient with hypokalemia?
- A. Monitor for muscle weakness
- B. Monitor for bradycardia
- C. Check deep tendon reflexes
- D. Monitor for hyperglycemia
Correct answer: A
Rationale: Corrected Rationale: Muscle weakness is a common symptom of hypokalemia and should be closely monitored in affected patients. Hypokalemia is a condition characterized by low potassium levels in the blood, which can lead to muscle weakness, cramps, and even paralysis. While bradycardia (slow heart rate) can be associated with severe hypokalemia, monitoring for muscle weakness is more specific to the condition. Checking deep tendon reflexes is not typically a primary monitoring parameter for hypokalemia. Monitoring for hyperglycemia is not directly related to hypokalemia, as hypokalemia is primarily associated with potassium levels in the blood.
2. A client with Ménière's disease is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan of care?
- A. Maintain strict bed rest
- B. Restrict fluid intake to the morning hours
- C. Administer aspirin
- D. Provide a low sodium diet
Correct answer: D
Rationale: The correct intervention for a client with Ménière's disease experiencing vertigo is to provide a low sodium diet. This helps reduce fluid retention, which can alleviate the symptoms of Ménière's disease. Maintaining strict bed rest is not necessary and can lead to deconditioning. Restricting fluid intake to the morning hours does not specifically address the underlying cause of Ménière's disease. Administering aspirin is not indicated for Ménière's disease and can potentially worsen symptoms.
3. What should be the first medication given for wheezing due to an allergic reaction?
- A. Albuterol via nebulizer
- B. Cromolyn via nebulizer
- C. Methylprednisolone IV
- D. Aminophylline 500 mg IV
Correct answer: A
Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line medication for treating wheezing caused by an allergic reaction as it works as a bronchodilator, helping to relieve the symptoms of wheezing and shortness of breath quickly. Cromolyn (choice B) is used more for preventing asthma symptoms rather than for immediate relief. Methylprednisolone IV (choice C) and Aminophylline 500 mg IV (choice D) are not the first-line treatments for wheezing due to an allergic reaction.
4. What are the expected signs of increased intracranial pressure (IICP)?
- A. Restlessness, confusion, irritability
- B. Severe headache and confusion
- C. Elevated blood pressure and bradycardia
- D. Bradycardia and altered pupil response
Correct answer: A
Rationale: The correct answer is A: Restlessness, confusion, irritability. These are early signs of increased intracranial pressure (IICP) and require prompt intervention. Restlessness, confusion, and irritability are indicative of the brain's attempt to compensate for the rising pressure. Choice B is incorrect because severe headache alone is not specific to IICP and can be present in various conditions. Choice C is incorrect because elevated blood pressure is not a common sign of IICP; instead, hypertension may be present in the compensatory stage. Choice D is incorrect as bradycardia and altered pupil response are signs of advanced IICP, not early signs. Monitoring and recognizing these early signs are crucial for timely intervention and preventing further complications.
5. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?
- A. Lie on your left side.
- B. Lie on your right side.
- C. Increase your fluid intake.
- D. Decrease your fluid intake.
Correct answer: B
Rationale: After a liver biopsy, the nurse should instruct the client to lie on the right side. This position helps apply pressure to the biopsy site, promoting hemostasis and reducing the risk of bleeding. Lying on the left side may not provide adequate pressure to the site. Increasing fluid intake is generally beneficial to prevent dehydration and aid in the recovery process, whereas decreasing fluid intake could lead to dehydration and possible complications. Therefore, the correct instruction is to lie on the right side.
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