ATI Capstone Medical Surgical Assessment 1 Quizlet

Correct Answer: B

Rationale: For a patient with ventricular tachycardia and a pulse, the appropriate action is synchronized cardioversion. Defibrillation is used for pulseless ventricular tachycardia or ventricular fibrillation. Pacing is typically used for bradycardias. Medication administration may be considered in stable ventricular tachycardia cases but electrical intervention is preferred for immediate correction in this scenario.

Correct Answer: A

Rationale: The correct answer is A: CD4 T-cell count 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV to assess the status of their immune system. A CD4 count of 180 cells/mm3 indicates severe immunocompromise and a high risk of opportunistic infections. This value is used to guide treatment decisions and assess the need for prophylaxis against specific infections. Choices B, C, and D are incorrect because monitoring white blood cell count, potassium levels, and hemoglobin levels, although important in HIV patients, are not as crucial as monitoring the CD4 T-cell count for assessing immune function and disease progression.

Correct Answer: C

Rationale: The priority action is to monitor the patient for signs of hypoglycemia as the nurse administered excess insulin due to misreading the glucose level. Administering glucose IV (Choice A) is not the immediate priority when dealing with hypoglycemia. Monitoring for hyperglycemia (Choice B) is not the correct action as the insulin was administered for a higher glucose reading. Documenting the incident (Choice D) is important but not the priority when the patient's safety is at risk due to possible hypoglycemia.

Correct Answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, tightening the connections of the chest tube system is the appropriate intervention. This action can often resolve an air leak, which is the common cause of continuous bubbling. Clamping the chest tube or replacing it is not recommended as the first-line intervention because it may lead to complications or unnecessary tube changes. Continuing to monitor the chest tube without addressing the air leak would delay necessary corrective action, potentially causing respiratory compromise in the patient. Therefore, tightening the connections of the chest tube system is the most suitable initial step to manage continuous bubbling in the water seal chamber.

Correct Answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. Monitoring the CD4 T-cell count is crucial in patients with HIV as it indicates the level of immunocompromise. A count below 180 cells/mm3 signifies severe immunocompromise and an increased risk of opportunistic infections. Choices B, C, and D are not the priority lab values in HIV management. While white blood cell count, serum albumin levels, and hemoglobin levels are important, they do not directly reflect the immune status and progression of HIV as the CD4 T-cell count does.