A client is being discharged following radioactive seed implantation for
prostate cancer. What is the mostimportant information that the nurse should
provide to this client’s family?
A.Follow exposure precautions.
B.Encourage regular meals.
C.Collect all urine.
D.Avoid touching the client.
Rationale:
Clients being treated for prostate cancer with radioactive seed implants should be
instructed regarding the amount oftime and distance needed to prevent excessive
exposure that would pose a hazard to others. Option B is a good suggestion to
promote adequate nutrition but is not as important as option A. Option C is
unnecessary. Contact with the client is permitted but should be brief to limit
radiation exposure.
In assessing a client with an arteriovenous (AV) shunt who is scheduled for
dialysis today, the nurse notes theabsence of a thrill or bruit at the shunt site.
What action should the nurse take?
A.Advise the client that the shunt is intact and
ready for dialysis asscheduled.
B.Encourage the client to keep the shunt site
elevated above the level ofthe heart.NUR NGN HESI MED SURG Exam Questions and Answers with Rationales Graded A+Latest update 2023/2024 GRADED A+ C.Notify the health care provider of the findings immediately.
D.Flush the site at least once with a heparinized saline solution.
Rationale:
Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse
should notify the health care provider so that intervention can be initiated to restore
function of the shunt. Option A is incorrect. Option B will notresolve the
obstruction. An AV shunt is internal and cannot be flushed without access using
special needles.
The nurse is concerned about infection for a client after an
esophagogastrostomy for esophageal cancer. Whichactions should the nurse
include in the client’s plan of care? ( Select all that apply. )
A.Frequent oral care every 2 hours while awake.
B.Use incentive spirometer every 2 hours.
C.Empty contents from NG tube every 8 hours.
D.Ambulate within 1 hour of return from the PACU.
E.Limit visitors until postoperative day 2.
Rationale:
One hour post op is too soon to ambulate for this client. Visitors help support the
patient and are encouraged to visit.Oral care is necessary as the client will be NPO.
To decrease the risk of infection post operatively, implement routine pulmonary exercises. The client will have an NG tube in place, likely to
intermittent suction, to decompressthe stomach post surgery.
The nurse notes that the client’s drainage has decreased from 50 to 5 mL/hr 12
hours after chest tube insertion forhemothorax. What is the best initial action for
the nurse to take?
A.Document this expected decrease in drainage.
B.Clamp the chest tube while assessing for air leaks.
C.Milk the tube to remove any excessive blood clot buildup.
D.Assess for kinks or dependent loops in the tubing.
Rationale:
The least invasive nursing action should be performed first to determine why the
drainage has diminished. Option Ais completed after assessing for any problems
causing the decrease in drainage. Option B is no longer considered standard
protocol because the increase in pressure may be harmful to the client. Option C is
an appropriate nursing action after the tube has been assessed for kinks or
dependent loops.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a
rapid ventricular response. Based onthis finding, the nurse anticipates assisting
the physician with which treatment?
A.Administer lidocaine, 75 mg intravenous push.
B.Perform synchronized cardioversion.
C.Defibrillate the client as soon as possible.
D.Administer atropine, 0.4 mg intravenous push.
Rationale: With uncontrolled atrial fibrillation, the treatment of choice is synchronized
cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A
is a medication used for ventricular dysrhythmias. Option C is not fora client with
atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such
as ventricular fibrillation and unstable ventricular tachycardia. Option D is the drug
of choice in symptomatic sinus bradycardia, not atrial fibrillation.
A practical nurse (PN) tells the charge nurse in a long-term facility that she does
not want to be assigned to one particular resident. She reports that the male client
keeps insisting that she is his daughter and begs her to stay in hisroom. What is
the best managerial decision?
A.Notify the family that the resident will have to
be discharged if hisbehavior does not improve.
B.Notify administration of the PN’s
insubordination and need forcounseling
about her statements.
C.Ask the PN what she has done to encourage the
resident to believethat she is his daughter.
D.Reassign the PN until the resident can be
assessed more completelyfor reality orientation.
Rationale:
Temporary reassignment is the best option until the resident can be examined and
his medications reviewed. He mayhave worsening cerebral dysfunction from an
infection or electrolyte imbalance. Option A is not the best option because the
family cannot control the resident’s actions. The administration may need to know
about the situation, but not as a case of insubordination. Implying that the PN is
somehow creating the situation is inappropriate until a further evaluation has been
conducted.
prostate cancer. What is the mostimportant information that the nurse should
provide to this client’s family?
A.Follow exposure precautions.
B.Encourage regular meals.
C.Collect all urine.
D.Avoid touching the client.
Rationale:
Clients being treated for prostate cancer with radioactive seed implants should be
instructed regarding the amount oftime and distance needed to prevent excessive
exposure that would pose a hazard to others. Option B is a good suggestion to
promote adequate nutrition but is not as important as option A. Option C is
unnecessary. Contact with the client is permitted but should be brief to limit
radiation exposure.
In assessing a client with an arteriovenous (AV) shunt who is scheduled for
dialysis today, the nurse notes theabsence of a thrill or bruit at the shunt site.
What action should the nurse take?
A.Advise the client that the shunt is intact and
ready for dialysis asscheduled.
B.Encourage the client to keep the shunt site
elevated above the level ofthe heart.NUR NGN HESI MED SURG Exam Questions and Answers with Rationales Graded A+Latest update 2023/2024 GRADED A+ C.Notify the health care provider of the findings immediately.
D.Flush the site at least once with a heparinized saline solution.
Rationale:
Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse
should notify the health care provider so that intervention can be initiated to restore
function of the shunt. Option A is incorrect. Option B will notresolve the
obstruction. An AV shunt is internal and cannot be flushed without access using
special needles.
The nurse is concerned about infection for a client after an
esophagogastrostomy for esophageal cancer. Whichactions should the nurse
include in the client’s plan of care? ( Select all that apply. )
A.Frequent oral care every 2 hours while awake.
B.Use incentive spirometer every 2 hours.
C.Empty contents from NG tube every 8 hours.
D.Ambulate within 1 hour of return from the PACU.
E.Limit visitors until postoperative day 2.
Rationale:
One hour post op is too soon to ambulate for this client. Visitors help support the
patient and are encouraged to visit.Oral care is necessary as the client will be NPO.
To decrease the risk of infection post operatively, implement routine pulmonary exercises. The client will have an NG tube in place, likely to
intermittent suction, to decompressthe stomach post surgery.
The nurse notes that the client’s drainage has decreased from 50 to 5 mL/hr 12
hours after chest tube insertion forhemothorax. What is the best initial action for
the nurse to take?
A.Document this expected decrease in drainage.
B.Clamp the chest tube while assessing for air leaks.
C.Milk the tube to remove any excessive blood clot buildup.
D.Assess for kinks or dependent loops in the tubing.
Rationale:
The least invasive nursing action should be performed first to determine why the
drainage has diminished. Option Ais completed after assessing for any problems
causing the decrease in drainage. Option B is no longer considered standard
protocol because the increase in pressure may be harmful to the client. Option C is
an appropriate nursing action after the tube has been assessed for kinks or
dependent loops.
A client on telemetry has a pattern of uncontrolled atrial fibrillation with a
rapid ventricular response. Based onthis finding, the nurse anticipates assisting
the physician with which treatment?
A.Administer lidocaine, 75 mg intravenous push.
B.Perform synchronized cardioversion.
C.Defibrillate the client as soon as possible.
D.Administer atropine, 0.4 mg intravenous push.
Rationale: With uncontrolled atrial fibrillation, the treatment of choice is synchronized
cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A
is a medication used for ventricular dysrhythmias. Option C is not fora client with
atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such
as ventricular fibrillation and unstable ventricular tachycardia. Option D is the drug
of choice in symptomatic sinus bradycardia, not atrial fibrillation.
A practical nurse (PN) tells the charge nurse in a long-term facility that she does
not want to be assigned to one particular resident. She reports that the male client
keeps insisting that she is his daughter and begs her to stay in hisroom. What is
the best managerial decision?
A.Notify the family that the resident will have to
be discharged if hisbehavior does not improve.
B.Notify administration of the PN’s
insubordination and need forcounseling
about her statements.
C.Ask the PN what she has done to encourage the
resident to believethat she is his daughter.
D.Reassign the PN until the resident can be
assessed more completelyfor reality orientation.
Rationale:
Temporary reassignment is the best option until the resident can be examined and
his medications reviewed. He mayhave worsening cerebral dysfunction from an
infection or electrolyte imbalance. Option A is not the best option because the
family cannot control the resident’s actions. The administration may need to know
about the situation, but not as a case of insubordination. Implying that the PN is
somehow creating the situation is inappropriate until a further evaluation has been
conducted.
