ATI RN Adult Medical Surgical Exam

Correct Answer D: Wear a lead apron when providing client care.

Explanation of the Correct Answer:

When caring for a client undergoing internal radiation therapy (brachytherapy), the nurse should wear a lead apron to minimize radiation exposure. Lead aprons provide essential shielding from the radiation source, especially when close physical contact with the client is required. Radiation exposure should always be minimized by following time, distance, and shielding protocols, with shielding—such as a lead apron—being a primary method for protection.

Why the Other Options Are Incorrect:

A. Place a dosimeter on the client's gown.

A dosimeter is a radiation detection device worn by healthcare workers to monitor their own exposure to radiation—not by the client. It should be worn by staff providing care to ensure they stay within safe exposure limits.

B. Ensure the door to the client's room remains open.

The door to the client's room should remain closed to contain radiation and protect others in the surrounding area. Proper signage should also be posted to indicate that radiation therapy is in use.

C. Wear sterile gloves during patient care.

Sterile gloves are not required unless performing a sterile procedure. Standard precautions apply, and radiation protection is the priority—not sterility—unless clinically indicated. Regular clean gloves are typically sufficient.

Correct Answer A: Drink 4 to 6 ounces of juice.

Explanation of the Correct Answer

For a mild to moderate hypoglycemic episode, the nurse should instruct the client to consume 15 grams of fast-acting carbohydrates, such as 4 to 6 ounces of fruit juice. This quickly raises blood glucose levels. After 15 minutes, the client should recheck their blood glucose and repeat the treatment if levels are still low.

Why the Other Options Are Incorrect:

B. Eat two crackers with peanut butter.

While peanut butter and crackers provide sustained energy, they contain fat, which slows carbohydrate absorption and delays glucose correction. This is more suitable for preventing a drop in blood glucose, not for treating acute hypoglycemia.

C. Consume 1 teaspoon of corn syrup-based glucose gel.

One teaspoon of glucose gel typically provides only about 5 grams of carbohydrates, which is less than the recommended 15 grams needed to treat hypoglycemia effectively.

D. Consume two glucose tablets and check your blood glucose 1 hour later.

Most glucose tablets contain about 4 grams of carbohydrate each, so two would only provide 8 grams—insufficient to treat hypoglycemia. Also, the client should recheck their blood glucose after 15 minutes, not 1 hour.

Correct Answer:

Document the donation number of the unit of blood on the client's electronic medical record.

Explanation:

Documenting the donation number of the blood unit is a critical part of the transfusion process. It ensures traceability of the blood product, which is essential in the event of a transfusion reaction, recall, or investigation. This documentation helps the blood bank or medical team identify the exact unit transfused and track its usage. Proper record-keeping in the client's electronic medical record is a safety protocol that ensures accountability and supports patient safety during the transfusion.

Why Other Options Are Wrong:

Prime the blood administration IV tubing with lactated Ringer's.

This is incorrect because lactated Ringer's solution contains calcium, which can cause clotting of the blood product. Only normal saline (0.9% sodium chloride) is compatible with blood transfusions. Using lactated Ringer's can lead to clot formation or hemolysis of the blood, which is dangerous and can cause complications.

Check the first set of vital signs 30 min after the blood infusion is started.

This is incorrect because vital signs should be taken immediately before starting the transfusion to establish a baseline. After the transfusion begins, the first set of vital signs should typically be taken 15 minutes into the infusion, as most reactions occur within this time frame. Waiting 30 minutes would delay detection of any early transfusion reactions, potentially compromising patient safety.

Infuse the unit of blood to the client over 6 hr.

This is incorrect because a unit of blood must be infused within 4 hours of removal from refrigeration to minimize the risk of bacterial growth and infection. Infusing blood over 6 hours exceeds this safe time limit, increasing the risk of infection and other complications. The 4-hour window is a critical safety standard in blood transfusion protocols.

Correct Answer:

Check the client's gag reflex.

Explanation:

Following a bronchoscopy, the client's airway is temporarily anesthetized to suppress the gag reflex and reduce discomfort during the procedure. This suppression puts the client at high risk for aspiration if they consume fluids or food too soon. Therefore, the immediate nursing priority is to verify that the gag reflex has returned before allowing any oral intake or initiating further education. This assessment ensures the client can safely protect their airway, which is fundamental in preventing serious complications such as aspiration pneumonia. Restoring airway protection is a critical first step in post-procedure care.

Why Other Options Are Wrong:

"Inform the client they might experience a low-grade fever."

This is incorrect because although a low-grade fever can occur after bronchoscopy due to minor airway irritation, it is not the first concern immediately following the procedure. Patient safety takes priority, specifically airway protection. Teaching about possible post-procedure symptoms can wait until after the client’s immediate risk of aspiration has been ruled out.

"Provide the client with sips of water."

This is incorrect because giving the client anything by mouth before confirming the return of the gag reflex can lead to choking or aspiration. The throat may still be numb from local anesthesia used during the bronchoscopy. Administering fluids prematurely disregards the fundamental principle of maintaining airway safety.

"Instruct the client to report bleeding."

This is incorrect because although bleeding is a potential complication of bronchoscopy and should be monitored for, it is not the first priority action. The client’s ability to swallow and protect their airway must be confirmed before providing any further instructions. Once the gag reflex is assessed and confirmed, the nurse can then proceed with teaching about symptoms to watch for, including bleeding.

Correct Answer B: Respiratory rate 14/min

Explanation of the Correct Answer:

A respiratory rate of 14 breaths per minute falls within the normal adult range (12–20/min) and indicates stable respiratory status, which is expected during recovery after an esophagogastroduodenoscopy (EGD). Monitoring respiratory function is important due to the use of sedation during the procedure, and a normal respiratory rate suggests that the client is recovering as expected without respiratory depression or distress.

Why the Other Options Are Incorrect:

A. Temperature 38.7° C (101.7° F)

An elevated temperature after an EGD can indicate a possible complication such as perforation or infection. This is not an expected finding and should be reported immediately.

C. Heart rate 110/min

A heart rate of 110 bpm is considered tachycardia and may indicate pain, anxiety, bleeding, or another complication. It is not a normal finding during recovery and requires further assessment.

D. SpO₂ 92%

While 92% is borderline acceptable, it is lower than the ideal range for most adults (typically ≥94%). This could indicate mild hypoxia, especially concerning after sedation, and should be monitored closely.

Correct Answer:

Wears clean gloves when caring for the client.

Explanation:

This answer is correct because MRSA is transmitted through direct contact with infected surfaces, wounds, or bodily fluids. To prevent the spread of MRSA, it is crucial to wear clean gloves whenever touching the client or any items in their environment that might be contaminated. Proper hand hygiene and barrier protection, such as gloves, are essential for contact precautions.

Why Other Options Are Incorrect:

Remains 3 feet away from the client

This is incorrect because the 3-foot distance applies to droplet precautions, not contact precautions. MRSA requires contact precautions, not necessarily limiting physical distance, as it is primarily spread by direct contact with infected areas or surfaces. Personal protective equipment (PPE), such as gloves and gowns, is the focus for MRSA.

Wears an N95 mask when providing wound care

This is incorrect because N95 respirators are required for airborne precautions, such as with tuberculosis or varicella, not MRSA. Unless the MRSA infection is in the lungs or if an aerosol-generating procedure is being done (which is rare), an N95 mask is not necessary. A surgical mask may be used during certain procedures, but it is not needed for routine wound care.

Disposes of isolation gown outside of the client's room

This is incorrect because isolation gowns should always be removed and disposed of inside the client's room to prevent contaminating other areas. If the gown is removed outside the room, it increases the risk of spreading contamination to the surrounding environment.

Summary:

The correct answer is Wears clean gloves when caring for the client, as this is the appropriate infection control measure for MRSA, which requires contact precautions. The other options are either related to other types of precautions (droplet or airborne) or violate proper infection control procedures.

Correct Answer:

Xerostomia

Explanation:

Xerostomia is the correct answer because it refers to dry mouth, which is a common side effect of radiation therapy to the head and neck. Radiation can damage the salivary glands, reducing saliva production and causing oral dryness. This leads to difficulties in speaking, swallowing, and maintaining oral hygiene. Managing xerostomia involves encouraging frequent hydration, using sugar-free gum or candies to stimulate saliva production, and maintaining good oral care to prevent infections and cavities. It is an expected and manageable complication in patients undergoing radiation in these areas.

Why Other Options Are Wrong:

Diplopia

This is incorrect because diplopia, or double vision, is not typically associated with radiation therapy to the head and neck unless the radiation specifically targets areas around the eyes or brain. Diplopia is more commonly caused by neurological issues, such as cranial nerve damage, stroke, or eye disorders, not from radiation to the head and neck unless those areas are directly affected.

Epistaxis

This is incorrect because epistaxis, or nosebleeds, are not a usual side effect of radiation therapy to the head and neck. Epistaxis is typically caused by factors like dry air, trauma, hypertension, or clotting disorders. While radiation can cause irritation of mucosal tissues, nosebleeds are not a standard consequence unless the nasal passages are directly exposed to radiation.

Tinnitus

This is incorrect because tinnitus, or ringing in the ears, is not a common side effect of radiation therapy to the head and neck. Tinnitus is more often linked to factors like ototoxic drugs, ear infections, or exposure to loud noises. Unless radiation directly affects ear structures, it is not typically associated with tinnitus.

Correct Answer A: Point the tip of the syringe toward the top of the ear canal.

Explanation of the Correct Answer:

When performing ear irrigation, the nurse should point the tip of the syringe toward the upper wall (roof) of the ear canal to avoid direct pressure on the tympanic membrane and to allow the irrigation fluid to flow out properly, reducing the risk of injury.

Why the Other Options Are Incorrect:

B. Insert the tip of the syringe 2.5 cm (1 in) into the ear canal

Inserting the syringe tip deeply into the ear canal risks damaging the ear canal or tympanic membrane. The tip should remain just at the canal entrance.

C. Use cool fluid for irrigation

Irrigation fluid should be warmed to near body temperature to prevent dizziness or vertigo caused by temperature differences in the ear canal.

D. Tilt the client’s head 45°

The client’s head should be tilted toward the side being irrigated, but not necessarily at a strict 45-degree angle. The key is to position the head so the fluid drains out easily.

Correct Answer C: Distended neck veins

Explanation of the Correct Answer:

Distended neck veins are a classic sign of fluid volume overload, indicating increased central venous pressure. D5W, though initially isotonic, becomes hypotonic once dextrose is metabolized, allowing free water to enter cells and potentially cause fluid retention if administered excessively. Monitoring for signs such as neck vein distention is critical to detect early signs of overload.

Why the Other Options Are Incorrect:

A. Altered level of consciousness

This may occur with severe fluid shifts or hyponatremia, but it is not an early or specific sign of fluid volume overload.

B. Hypotension

Fluid volume overload typically results in hypertension or normal blood pressure, not hypotension.

D. Skin tenting of the forearm

Skin tenting suggests dehydration, not fluid overload. In volume overload, the skin would typically be moist with good turgor.