7. A nurse is teaching a client who has ovarian cancer about skin care following radiation treatment. Which of the
following instructions should the nurse include?
a. Pat the skin on the radiation site to dry it
b. Apply OTC moisturizer to the radiation site
c. Cover the radiation site loosely with a gauze wrap before dressing
d. Use a soft washcloth to clean the area around the radiation site
Rationale: pg. 584. Dry the area thoroughly using patting motions.
8. A nurse is caring for a client who is receiving a blood transfusion. The nurse observes that the client has
bounding peripheral pulses, hypertension, and distended jugular veins. The nurse should anticipate administering which of the
following prescribed medications?
a. Diphenhydramine
b. Acetaminophen
c. Pantoprazole
d. Furosemide
Rationale: S/S may indicate fluid retention or heart failure. It is important to administer diuretics to prevent
cardiovascular/respiratory distress.
9. A nurse is assessing a client who is receiving magnesium sulfate IV for the treatment of hypomagnesemia.
Which of the following findings indicates effectiveness of the medication?
a. Lungs clear
b. Apical pulse 82/min
c. Hyperactive bowel sounds
d. Blood pressure 90/50 mm Hg
Rationale: pg. 278 Confirmed on answer sheet
10. A nurse is reviewing a client’s ABG results pH 7.42, PaC02 30 mm Hg, and HCO3 21 mEq/L. The nurse should recognize
these findings as indication of which of the following conditions?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Compensated respiratory alkalosis
d. Uncompensated respiratory acidosis
Rationale: because the HCO3 21 trying to compensate for respiratory alkalosis.
11. A nurse is caring for a client who has a deep partial thickness burns over 15% of her body which of the following labs
should the nurse expect during the first 24 hours
A. Decreased BUN (elevated due to fluid loss)
B. Hypoglycemia (High due to stress)
C. Hypoalbuminemia (Low due to fluid loss)
D. Decreased Hematocrit (Elevated due to 3rd spacing during resuscitation phase)
Rationale: Pg. 481 ATI. Total protein and albumin- low due to fluid loss.
12. A nurse is caring for a client who has dumping syndrome following a gastrectomy, which of the following actions should
the nurse takes?
a. Offer the client high carbohydrate meal options (High fat, high protein, low fiber, low to moderate carbs page
317, chapter 49 Peptic ulcer disease med surg ATI PDF 10.0)
b. Provide the client with four full meals a day (Small frequent meals)
c. Encourage the client to drink at least 360 ml of fluids with meals (Eliminate liquids with meals for 1 hr. prior
and following a meal)
d. Have the client lie down for 30 minutes after meals (Lying down after a meal slows the movement of food
within the intestines)
Rationale: ATI pg. 318 Dumping syndromes is a term that refers to a constellation of vasomotor symptoms that occurs after eating,
especially following a Billroth II procedure. Early manifestations usually occur within 30 minutes of eating and include vertigo,
tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. The nurse should instruct the client to decrease the
Med Surg 2016→PRIORITY TWO1.A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings shouldthe nurse report to the surgeon?a.Heart rate 90/minb.Absent bowel soundsc.Hgb 8.2 g/dld.Gastric pH of 3.0Rationale: Normal Hgb is 13-18M g/dl, 12-16 g/dl. This may indicate a possible hemorrhaging.