nurse maria is preparing a care plan for a client receiving external radiation therapy which of the following interventions should be included nurse maria is preparing a care plan for a client receiving external radiation therapy which of the following interventions should be included
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Nursing Elites

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ATI Oncology Questions

1. Nurse Maria is preparing a care plan for a client receiving external radiation therapy. Which of the following interventions should be included?

Correct answer: B

Rationale: Radiation therapy can cause skin irritation, dryness, and sensitivity in the treated area. Wearing loose, soft clothing helps minimize friction and pressure on the skin, reducing irritation and promoting comfort. The skin in the treated area is often more sensitive and vulnerable to damage, so this intervention helps protect the skin while maintaining the client’s comfort during the course of treatment.

2. A nurse is caring for a client who has septic shock. Which of the following findings should the nurse report to the provider?

Correct answer: B

Rationale: The correct answer is B. A urinary output of 40 mL/hr is below the expected range and should be reported to the provider as it may indicate impaired kidney function, which is crucial to monitor in a client with septic shock. Choices A, C, and D are within acceptable ranges for a client with septic shock and do not indicate immediate concerns. A temperature of 38°C (100.4°F) is slightly elevated but can be expected in septic shock. A heart rate of 92/min is within the normal range for an adult. A capillary refill time of 2 seconds is also normal, indicating adequate peripheral perfusion.

3. In a normally functioning cardiovascular system, where does the heartbeat originate?

Correct answer: Sinoatrial node

Rationale: The correct answer is the Sinoatrial (SA) node. The SA node is known as the natural pacemaker of the heart as it initiates the electrical impulses responsible for the heartbeat. The other choices, such as the Atrioventricular (AV) nodes, Bundle of His, and Purkinje fibers, are involved in conducting the electrical signals generated by the SA node to coordinate the heart's contractions. Therefore, they do not serve as the primary origin of the heartbeat.

4. An RN cared for a state senator during the day shift. Later that day he was having dinner with friends when the news mentioned the senator had been hospitalized. The RN�s friends asked if he knew what was wrong with the senator. Which ethical principle should the RN consider when replying?

Correct answer: B

Rationale: The principle of confidentiality requires nurses to hold healthcare information and anything patients tell them in the strictest confidence.

5. What is the first action a healthcare provider should take for a patient with possible acute coronary syndrome?

Correct answer: A

Rationale: Administering sublingual nitroglycerin is the initial priority action for a patient with possible acute coronary syndrome. Nitroglycerin helps dilate blood vessels, reduce chest pain, and improve blood flow to the heart muscle. This helps in relieving symptoms and preventing further damage to the heart. Establishing IV access, auscultating heart sounds, and obtaining cardiac enzymes are important steps in the assessment and management of acute coronary syndrome but are not the first actions to be taken. IV access may be needed for administering medications or fluids, auscultating heart sounds helps in assessing the heart's function, and obtaining cardiac enzymes aids in diagnosing a heart attack.

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