VATI Med-Surg Post-Assessment
A charge nurse is assigning the care of a client who has an internal radiation implant. Which of
the following actions should the nurse take?
A. Assign the client to a semi-private room with another client who has a fractured tibia.
B. Assign the client to nurses who are not pregnant or trying to conceive.
C. Instruct visitors that they must remain 3 feet away from the client.
D. Instruct visitors that visits should be no longer than 60 min. - ANS -B. Assign the client to
nurses who are not pregnant or trying to conceive.
Radiation can be tetrogenic to fetuses. Staff who are pregnant or are trying to conceive should
not be exposed to the client due to the risk of radiation exposure.
The client who is receiving internal radiation through an implanted device requires a private
room. This prevents accidental injury to another client due to the risk of radiation exposure. The
charge nurse should instruct all visitors to remain at least 6 feet away from the client to avoid
the risk of exposure to radiation. The nurse should instruct the visitors to limit visits to 30 min per
day to decrease the risk of radiation exposure.
\A client who is newly diagnosed with cancer has been prescribed oral chemotherapy. The client
tells the nurse, "I'm not sure if I want to take this medicine." Which of the following responses
should the nurse make?
A. "I think you should seriously consider the consequences of not going through with treatment."
B. "You do not have to take any medications that you don't want to."
C. "Tell me more about what is making you feel unsure about taking this medication."
D. "Are you nervous about the side effects of chemotherapy?" - ANS -C. "Tell me more about
what is making you feel unsure about taking this medication."
This is an open-ended statement that allows the client to express their concerns about the
treatment plan.
\A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the
following findings should the nurse report to the provider?
A. There is 2 cm (0.79 in) of water in the water seal chamber.
B. There is continuous bubbling in the suction chamber.
C. The fluid in the collection chamber is draining at 75 mL/hr.
D. The level in the water seal chamber rises when the client inhales. - ANS -C. The fluid in the
collection chamber is draining at 75 mL/hr.
, An increase in drainage greater than 70 mL/hr is an indication the client might be bleeding. The
nurse should report this finding to the provider.
\A nurse is assessing a client who has right-sided heart failure. Which of the following findings
should the nurse expect?
A. Elevated central venous pressure
B. Presence of S3 ventricular gallop
C. Elevated pulmonary artery wedge pressure
D. Orthopnea at night - ANS -A. Elevated central venous pressure
The nurse should expect a client who has right-sided heart failure to have an elevated central
venous pressure due to right ventricular failure. Central venous pressure is the pressure in the
vena cava, near the right atrium of the heart, which reflects the amount of blood returning to the
heart.
Presence of S3 ventricular gallop can be detected in clients who have left-sided heart failure
due to altered ventricular filling. Pulmonary pressure increases in left-sided heart failure
because of the increased pressure and volume of blood in the left ventricle. Orthopnea, or
difficulty breathing when lying flat, is a manifestation of left-sided heart failure due to pulmonary
congestion.
\A nurse is assessing a client who is postoperative following surgery using general anesthesia.
Which of the following findings is the priority to report to the provider?
A. Client report pain as 5 on a scale of 0 to 10
B. A decrease in blood pressure from 130/72 to 110/68 mm Hg
C. Absent bowel sounds
D. Client report of nausea - ANS -B. A decrease in blood pressure from 130/72 to 110/68 mm
Hg
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is a decrease in blood pressure because this can be an indication of fluid
volume deficit or hemorrhage.
\A nurse is assessing a client who is receiving hemodialysis. Which of the following findings is
the nurse's priority to report to the provider?
A. Nausea
B. Hypotension
C. Headache
D. Diaphoresis - ANS -B. Hypotension
When using the airway, breathing, and circulation priority framework, the nurse should recognize
that hypotension is the priority finding to report to the provider for a client who is receiving
hemodialysis. A client who is receiving hemodialysis is at risk for vasodilation due to the
introduction of a warm fluid into the bloodstream, which can result in a drop in blood pressure.
A charge nurse is assigning the care of a client who has an internal radiation implant. Which of
the following actions should the nurse take?
A. Assign the client to a semi-private room with another client who has a fractured tibia.
B. Assign the client to nurses who are not pregnant or trying to conceive.
C. Instruct visitors that they must remain 3 feet away from the client.
D. Instruct visitors that visits should be no longer than 60 min. - ANS -B. Assign the client to
nurses who are not pregnant or trying to conceive.
Radiation can be tetrogenic to fetuses. Staff who are pregnant or are trying to conceive should
not be exposed to the client due to the risk of radiation exposure.
The client who is receiving internal radiation through an implanted device requires a private
room. This prevents accidental injury to another client due to the risk of radiation exposure. The
charge nurse should instruct all visitors to remain at least 6 feet away from the client to avoid
the risk of exposure to radiation. The nurse should instruct the visitors to limit visits to 30 min per
day to decrease the risk of radiation exposure.
\A client who is newly diagnosed with cancer has been prescribed oral chemotherapy. The client
tells the nurse, "I'm not sure if I want to take this medicine." Which of the following responses
should the nurse make?
A. "I think you should seriously consider the consequences of not going through with treatment."
B. "You do not have to take any medications that you don't want to."
C. "Tell me more about what is making you feel unsure about taking this medication."
D. "Are you nervous about the side effects of chemotherapy?" - ANS -C. "Tell me more about
what is making you feel unsure about taking this medication."
This is an open-ended statement that allows the client to express their concerns about the
treatment plan.
\A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the
following findings should the nurse report to the provider?
A. There is 2 cm (0.79 in) of water in the water seal chamber.
B. There is continuous bubbling in the suction chamber.
C. The fluid in the collection chamber is draining at 75 mL/hr.
D. The level in the water seal chamber rises when the client inhales. - ANS -C. The fluid in the
collection chamber is draining at 75 mL/hr.
, An increase in drainage greater than 70 mL/hr is an indication the client might be bleeding. The
nurse should report this finding to the provider.
\A nurse is assessing a client who has right-sided heart failure. Which of the following findings
should the nurse expect?
A. Elevated central venous pressure
B. Presence of S3 ventricular gallop
C. Elevated pulmonary artery wedge pressure
D. Orthopnea at night - ANS -A. Elevated central venous pressure
The nurse should expect a client who has right-sided heart failure to have an elevated central
venous pressure due to right ventricular failure. Central venous pressure is the pressure in the
vena cava, near the right atrium of the heart, which reflects the amount of blood returning to the
heart.
Presence of S3 ventricular gallop can be detected in clients who have left-sided heart failure
due to altered ventricular filling. Pulmonary pressure increases in left-sided heart failure
because of the increased pressure and volume of blood in the left ventricle. Orthopnea, or
difficulty breathing when lying flat, is a manifestation of left-sided heart failure due to pulmonary
congestion.
\A nurse is assessing a client who is postoperative following surgery using general anesthesia.
Which of the following findings is the priority to report to the provider?
A. Client report pain as 5 on a scale of 0 to 10
B. A decrease in blood pressure from 130/72 to 110/68 mm Hg
C. Absent bowel sounds
D. Client report of nausea - ANS -B. A decrease in blood pressure from 130/72 to 110/68 mm
Hg
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is a decrease in blood pressure because this can be an indication of fluid
volume deficit or hemorrhage.
\A nurse is assessing a client who is receiving hemodialysis. Which of the following findings is
the nurse's priority to report to the provider?
A. Nausea
B. Hypotension
C. Headache
D. Diaphoresis - ANS -B. Hypotension
When using the airway, breathing, and circulation priority framework, the nurse should recognize
that hypotension is the priority finding to report to the provider for a client who is receiving
hemodialysis. A client who is receiving hemodialysis is at risk for vasodilation due to the
introduction of a warm fluid into the bloodstream, which can result in a drop in blood pressure.
