A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include?
"You will have an implant placed twice each month for the duration of the treatment."
"You should remain at least 6 feet a...
Med Surg ATI Practice A Questions &
Answers
A nurse is providing teaching to a client who has stage II cervical cancer and is
scheduled for brachytherapy. Which of the following instructions should the nurse
include?
"You will have an implant placed twice each month for the duration of the treatment."
"You should remain at least 6 feet away from others between treatments."
"You should expect to have blood in your urine for a few days after treatment."
"You will need to stay still in the bed during each treatment session." - ANSWERS"You
will need to stay still in the bed during each treatment session."
The nurse should instruct the client that they will need to remain on bed rest with very
limited movement because excessive movement can cause the radioactive source to
become dislodged.
A nurse in an emergency department is caring for a client who reports vomiting and
diarrhea for the past 3 days. Which of the following findings should indicate to the nurse
that the client is experiencing fluid volume deficit?
Heart rate 110/min
Blood pressure 138/90 mm Hg
Urine specific gravity 1.020
BUN 15 mg/dL - ANSWERSHeart rate 110/min
A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume
deficit and an elevated heart rate.
A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I
could stop these treatments. I am ready to die." Which of the following statements
should the nurse make?
"Discontinuing with the treatments is your choice if it is your wish to do so."
"Your child is named as your health care surrogate. I will ask them if you can stop the
treatments."
"I will call your spiritual advisor to come in, so you can discuss this with them."
"Next time you have an oncology appointment, you should ask the oncologist." -
ANSWERS"Discontinuing with the treatments is your choice if it is your wish to do so."
The nurse should recognize the client's right to refuse the treatments and inform the
client of this right. The nurse should advocate for the client and offer to contact the
provider for the client.
,A nurse is caring for a client who is receiving dialysis treatment..
For each potential nursing intervention, click to specify if the intervention is indicated or
not indicated. - ANSWERSINDICATED:
- Apply oxygen at 2 L/min via nasal cannula.
- Administer a 0.9% sodium chloride 200 mL IV bolus.
- Notify the provider immediately.
- Place the client in Trendelenburg position.
NOT INDICATED:
- Perform a 12-lead ECG.
- Obtain the client's blood glucose level.
A nurse is caring for a client who is postoperative. Which of the following actions should
the nurse take? Select all that apply. - ANSWERS- Instruct the client to splint the
abdomen with a pillow for coughing
- Plan to ambulate the client as soon as possible
- Report urinary output to the provider
- Ask the client to rate their pain on a 0 to 10 pain scale
Rationale:
- It is important for the client to turn, cough, and deep breathe to reduce the risk for
respiratory complications and reduce the risk of complications to the surgical incision.
- The nurse should plan to ambulate the client as soon as possible to promote
ventilation and decrease the risk of thrombosis.
- The client should produce at least 30 mL of urine per hour. Therefore, the nurse
should report this finding to the provider.
- The nurse should have the client rate their pain prior to and following the
administration of pain medication to evaluate its effectiveness.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag
is not available when the current infusion is nearly completed. Which of the following
actions should the nurse take?
1. Keep the line open with 0.9% sodium chloride until the new bag arrives.
2. Administer dextrose 10% in water until the new bag arrives.
3. Flush the line and cap the port until the new bag arrives.
4. Decrease the infusion rate until the new bag arrives. - ANSWERS2. Administer
dextrose 10% in water until the new bag arrives.
TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is
temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to
avoid a precipitous drop in the client's blood glucose level.
A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of
the following findings should the nurse report to the provider?
1. The client's urinary output has increased.
, 2. The client reports back pain.
3. The client's urine color is red tinged.
4. The client's BUN is 18 mg/dL. - ANSWERS2. The client reports back pain.
The nurse should notify the provider if the client reports back pain, which can indicate
that the nephrostomy tube is dislodged or clogged.
A nurse is caring for a client who is having a seizure. Which of the following
interventions is the nurse's priority?
1. Loosen the clothing around the client's neck.
2. Check the client's pupillary response.
3. Turn the client to the side.
4. Move furniture away from the client. - ANSWERS3. Turn the client to the side.
The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority
intervention the nurse should take is to place the client in a side-lying position to prevent
aspiration.
A nurse in a provider's office is assessing a client who has hypertension and takes
propranolol. Which of the following findings should indicate to the nurse that the client is
experiencing an adverse reaction to this medication?
1. Report of a night cough
2. Report of tinnitus
3. Report of excessive tearing
4. Report of increased salivation - ANSWERS1. Report of a night cough
The nurse should recognize that a night cough is an early indication of heart failure and
report this adverse reaction to the provider.
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has
a pressure injury. Which of the following actions should the nurse take?
Apply a wet-to-dry gauze dressing.
Irrigate with hydrogen peroxide solution.
Use a 30-mL syringe.
Attach a 24-gauge angiocatheter to the syringe. - ANSWERSUse a 30-mL syringe.
The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to
deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To
maintain healthy granulation tissue, the wound irrigation should be delivered at between
4 and 15 psi.
A nurse is assessing a client who has Graves' disease. Which of the following images
should indicate to the nurse that the client has exophthalmos? - ANSWERSEyes
bulging and wide open
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