ATI Capstone Medical Surgical Assessment 1 Quizlet

Correct Answer: A

Rationale: The correct first intervention for a patient admitted with unstable angina is to administer nitroglycerin. Nitroglycerin helps to relieve chest pain by dilating blood vessels and increasing blood flow to the heart, thereby reducing cardiac workload. This intervention aims to alleviate symptoms and prevent further cardiac damage. Obtaining cardiac enzymes (Choice B) is important for diagnosing a myocardial infarction but is not the initial intervention for unstable angina. Starting IV fluids (Choice C) may be indicated in specific cases like hypovolemia but is not the primary intervention for unstable angina. Monitoring for chest pain (Choice D) is essential but taking action to alleviate the pain, like administering nitroglycerin, is the primary focus in the initial management of unstable angina.

Correct Answer: A

Rationale: The correct answer is A: Flattened T waves on the ECG. Flattened T waves are an early indicator of hypokalemia on an ECG. Choice B, Elevated ST segments, is not typically seen in hypokalemia but can be a sign of myocardial infarction. Choice C, Widened QRS complex, is more commonly associated with hyperkalemia. Choice D, Prominent U waves, is typically associated with hypokalemia, but flattened T waves are considered a more specific and early sign.

Correct Answer: A

Rationale: The correct answer is to administer nitroglycerin. Nitroglycerin is the priority intervention for a patient with possible acute coronary syndrome as it helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart. This intervention is crucial in managing acute coronary syndrome and should be given promptly. Getting IV access may be necessary, but administering nitroglycerin takes precedence to alleviate symptoms and prevent further heart damage. Auscultating heart sounds and administering aspirin are important aspects of the assessment and treatment plan, but they are not the priority interventions in the acute phase of suspected acute coronary syndrome.

Correct Answer: B

Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.

Correct Answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. Nitroglycerin helps vasodilate coronary arteries, improving blood flow to the heart, relieving chest pain, and preventing cardiac tissue damage. Establishing IV access (choice B) is important but not the preferred initial treatment for unstable angina with chest pain. Auscultating heart sounds (choice C) and obtaining cardiac enzymes (choice D) are relevant assessments but do not address the immediate symptomatic relief needed for a patient with unstable angina and chest pain.