ATI Capstone Adult Medical Surgical Assessment 1

Correct Answer: B

Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.

Correct Answer: D

Rationale: The correct first action for the nurse to take when suspecting an adverse reaction to a blood transfusion is to stop the transfusion immediately. Stopping the transfusion helps prevent further harm to the client. Maintaining IV access and obtaining vital signs are important steps but come after stopping the transfusion in this situation. Contacting the provider can be done after ensuring the client's safety by stopping the transfusion.

Correct Answer: A

Rationale: The correct answer is A, Propofol. Propofol is a short-acting anesthetic medication commonly used for procedures like colonoscopies to induce moderate sedation. Pancuronium (Choice B) is a neuromuscular blocking agent used as a paralyzing agent during surgery, not for sedation. Promethazine (Choice C) is an antihistamine often used for nausea and vomiting, not as an anesthetic. Pentoxifylline (Choice D) is a medication used to improve blood flow and is not indicated for anesthesia.

Correct Answer: B

Rationale: The correct answer is B. Shortness of breath is an important sign of transplant rejection. Other manifestations of rejection include fatigue, edema, bradycardia, and hypotension. Choices A, C, and D are incorrect because: A) Immunosuppressant medications are typically required for life, not just up to 1 year. C) The surgical site healing time can vary and may take longer than 3 to 4 weeks. D) Starting a specific exercise regimen should be individualized and guided by healthcare providers; a general recommendation like 45 minutes of exercise per day may not be suitable for all heart transplant recipients.

Correct Answer: A

Rationale: In the scenario described, where the client has been experiencing repeated tonic-clonic seizures over an extended period, the priority is to administer a medication that can rapidly terminate the seizures. Diazepam is the medication of choice for status epilepticus due to its rapid onset of action within 10 minutes when administered intravenously. Lorazepam is also an option, but it is typically administered intravenously as well. Diltiazem is a calcium channel blocker used for conditions like hypertension and angina, not for seizures. Clonazepam, although used for seizures, is not the ideal choice in this acute situation due to its slower onset of action compared to benzodiazepines like diazepam and lorazepam.