VATI Med-Surg Post-Assessment
A rate nurse is assigning the care of a purchaser who has an inner radiation implant. Which of
the following actions must the nurse take?
A. Assign the client to a semi-private room with every other consumer who has a fractured tibia.
B. Assign the client to nurses who are not pregnant or seeking to conceive.
C. Instruct traffic that they should continue to be 3 feet faraway from the purchaser.
D. Instruct traffic that visits should be now not than 60 min. - ANS-B. Assign the consumer to
nurses who aren't pregnant or trying to conceive.
Radiation can be tetrogenic to fetuses. Staff who are pregnant or are trying to conceive ought to
not be exposed to the consumer because of the chance of radiation publicity.
The customer who's receiving internal radiation through an implanted tool requires a personal
room. This prevents unintentional damage to every other consumer due to the chance of
radiation exposure. The charge nurse have to coach all visitors to remain at least 6 feet away
from the consumer to avoid the risk of publicity to radiation. The nurse should train the visitors to
restriction visits to 30 min in step with day to decrease the threat of radiation exposure.
A consumer who's newly identified with cancer has been prescribed oral chemotherapy. The
patron tells the nurse, "I'm not certain if I need to take this medicinal drug." Which of the
subsequent responses need to the nurse make?
A. "I think you have to seriously don't forget the results of not going through with remedy."
B. "You do now not ought to take any medicinal drugs which you don't need to."
C. "Tell me extra approximately what is making you experience uncertain about taking this
medicinal drug."
D. "Are you anxious about the aspect results of chemotherapy?" - ANS-C. "Tell me more about
what is making you experience uncertain about taking this medication."
This is an open-ended assertion that permits the client to explicit their issues approximately the
treatment plan.
A nurse is assessing a purchaser who has a chest tube following a thoracotomy. Which of the
following findings need to the nurse record to the issuer?
A. There is 2 cm (0.Seventy nine in) of water in the water seal chamber.
B. There is non-stop effervescent in the suction chamber.
C. The fluid inside the collection chamber is draining at seventy five mL/hr.
, D. The level inside the water seal chamber rises whilst the purchaser inhales. - ANS-C. The fluid
within the series chamber is draining at 75 mL/hr.
An boom in drainage extra than 70 mL/hr is an indication the consumer is probably bleeding.
The nurse ought to report this locating to the company.
A nurse is assessing a customer who has right-sided coronary heart failure. Which of the
following findings need to the nurse count on?
A. Elevated critical venous stress
B. Presence of S3 ventricular gallop
C. Elevated pulmonary artery wedge pressure
D. Orthopnea at night - ANS-A. Elevated imperative venous strain
The nurse need to anticipate a consumer who has right-sided coronary heart failure to have an
accelerated principal venous pressure because of right ventricular failure. Central venous strain
is the strain inside the vena cava, close to the right atrium of the coronary heart, which reflects
the amount of blood returning to the coronary heart.
Presence of S3 ventricular gallop may be detected in customers who have left-sided heart
failure because of altered ventricular filling. Pulmonary stress increases in left-sided coronary
heart failure because of the multiplied stress and quantity of blood inside the left ventricle.
Orthopnea, or difficulty breathing whilst lying flat, is a manifestation of left-sided heart failure due
to pulmonary congestion.
A nurse is assessing a patron who is postoperative following surgical operation using popular
anesthesia. Which of the following findings is the priority to record to the issuer?
A. Client document pain as 5 on a scale of zero to 10
B. A decrease in blood pressure from one hundred thirty/seventy two to 110/sixty eight mm Hg
C. Absent bowel sounds
D. Client report of nausea - ANS-B. A lower in blood pressure from one hundred thirty/72 to
110/68 mm Hg
When the use of the pressing vs. Nonurgent approach to purchaser care, the nurse have to
determine that the priority finding is a lower in blood strain because this will be an illustration of
fluid extent deficit or hemorrhage.
A nurse is assessing a patron who is receiving hemodialysis. Which of the subsequent findings
is the nurse's priority to document to the issuer?
A. Nausea
B. Hypotension
C. Headache
A rate nurse is assigning the care of a purchaser who has an inner radiation implant. Which of
the following actions must the nurse take?
A. Assign the client to a semi-private room with every other consumer who has a fractured tibia.
B. Assign the client to nurses who are not pregnant or seeking to conceive.
C. Instruct traffic that they should continue to be 3 feet faraway from the purchaser.
D. Instruct traffic that visits should be now not than 60 min. - ANS-B. Assign the consumer to
nurses who aren't pregnant or trying to conceive.
Radiation can be tetrogenic to fetuses. Staff who are pregnant or are trying to conceive ought to
not be exposed to the consumer because of the chance of radiation publicity.
The customer who's receiving internal radiation through an implanted tool requires a personal
room. This prevents unintentional damage to every other consumer due to the chance of
radiation exposure. The charge nurse have to coach all visitors to remain at least 6 feet away
from the consumer to avoid the risk of publicity to radiation. The nurse should train the visitors to
restriction visits to 30 min in step with day to decrease the threat of radiation exposure.
A consumer who's newly identified with cancer has been prescribed oral chemotherapy. The
patron tells the nurse, "I'm not certain if I need to take this medicinal drug." Which of the
subsequent responses need to the nurse make?
A. "I think you have to seriously don't forget the results of not going through with remedy."
B. "You do now not ought to take any medicinal drugs which you don't need to."
C. "Tell me extra approximately what is making you experience uncertain about taking this
medicinal drug."
D. "Are you anxious about the aspect results of chemotherapy?" - ANS-C. "Tell me more about
what is making you experience uncertain about taking this medication."
This is an open-ended assertion that permits the client to explicit their issues approximately the
treatment plan.
A nurse is assessing a purchaser who has a chest tube following a thoracotomy. Which of the
following findings need to the nurse record to the issuer?
A. There is 2 cm (0.Seventy nine in) of water in the water seal chamber.
B. There is non-stop effervescent in the suction chamber.
C. The fluid inside the collection chamber is draining at seventy five mL/hr.
, D. The level inside the water seal chamber rises whilst the purchaser inhales. - ANS-C. The fluid
within the series chamber is draining at 75 mL/hr.
An boom in drainage extra than 70 mL/hr is an indication the consumer is probably bleeding.
The nurse ought to report this locating to the company.
A nurse is assessing a customer who has right-sided coronary heart failure. Which of the
following findings need to the nurse count on?
A. Elevated critical venous stress
B. Presence of S3 ventricular gallop
C. Elevated pulmonary artery wedge pressure
D. Orthopnea at night - ANS-A. Elevated imperative venous strain
The nurse need to anticipate a consumer who has right-sided coronary heart failure to have an
accelerated principal venous pressure because of right ventricular failure. Central venous strain
is the strain inside the vena cava, close to the right atrium of the coronary heart, which reflects
the amount of blood returning to the coronary heart.
Presence of S3 ventricular gallop may be detected in customers who have left-sided heart
failure because of altered ventricular filling. Pulmonary stress increases in left-sided coronary
heart failure because of the multiplied stress and quantity of blood inside the left ventricle.
Orthopnea, or difficulty breathing whilst lying flat, is a manifestation of left-sided heart failure due
to pulmonary congestion.
A nurse is assessing a patron who is postoperative following surgical operation using popular
anesthesia. Which of the following findings is the priority to record to the issuer?
A. Client document pain as 5 on a scale of zero to 10
B. A decrease in blood pressure from one hundred thirty/seventy two to 110/sixty eight mm Hg
C. Absent bowel sounds
D. Client report of nausea - ANS-B. A lower in blood pressure from one hundred thirty/72 to
110/68 mm Hg
When the use of the pressing vs. Nonurgent approach to purchaser care, the nurse have to
determine that the priority finding is a lower in blood strain because this will be an illustration of
fluid extent deficit or hemorrhage.
A nurse is assessing a patron who is receiving hemodialysis. Which of the subsequent findings
is the nurse's priority to document to the issuer?
A. Nausea
B. Hypotension
C. Headache
