ATI Capstone Adult Medical Surgical Assessment 2

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.

Correct Answer: A

Rationale: Administering sublingual nitroglycerin is the initial priority action for a patient with possible acute coronary syndrome. Nitroglycerin helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart muscle. This helps in relieving symptoms and preventing further damage to the heart. Establishing IV access, auscultating heart sounds, and obtaining cardiac enzymes are important steps in the assessment and management of acute coronary syndrome but are not the first actions to be taken. IV access may be needed for administering medications or fluids, auscultating heart sounds helps in assessing the heart's function, and obtaining cardiac enzymes aids in diagnosing a heart attack.

Correct Answer: A

Rationale: In a patient with chest pain, possible acute coronary syndrome, the nurse should administer sublingual nitroglycerin first. Nitroglycerin helps to vasodilate coronary arteries, improving blood flow to the heart, and reducing cardiac workload. This can alleviate chest pain and decrease cardiac tissue damage in acute coronary syndrome. Getting IV access, obtaining cardiac enzymes, and auscultating heart sounds are important steps in the assessment and management of acute coronary syndrome, but administering nitroglycerin to relieve chest pain and improve blood flow takes precedence as it directly addresses the patient's symptoms and aims to prevent further cardiac damage.

Correct Answer: A

Rationale: The correct dietary recommendation for a patient with pre-dialysis end-stage kidney disease is to limit phosphorus intake to 700 mg/day. Excess phosphorus can be harmful to individuals with kidney disease as their kidneys are not able to remove it effectively. Choice B is incorrect as increasing sodium intake is generally not recommended for individuals with kidney disease due to its association with high blood pressure. Choice C is also incorrect as protein restriction is a common recommendation for patients with advanced kidney disease, but the range provided is not accurate. Choice D is incorrect as eating three large meals per day may not be suitable for managing the condition.

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.