VATI Fundamentals Exam_2020 | VATI Fundamentals Exam_Graded A - $15.99   Add to cart

Exam (elaborations)

VATI Fundamentals Exam_2020 | VATI Fundamentals Exam_Graded A

VATI Fundamentals Exam_2020 A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose? (Use a leading zero if it applies. Do not use a trailing zero. Round the answer to the nearest tenth.) 0.4 A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected clients who have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for which of the following clients? A client who has chronic back pain and a history of being physically abused Therapeutic touch consists of using the nurse's hands to harmonize energy fields and to facilitate relief of pain or anxiety, such as for a client who has chronic back pain. The nurse can touch the client with their palms or move the palms near, but not touching the client's body. Prior physical maltreatment and some mental health disorders are contraindications for therapeutic touch, because touch or near touch could cause severe anxiety. A nurse in a rehabilitation unit is assessing a group of clients who have traumatic brain injuries. The nurse should identify that which of the following clients requires a priority referral? A client who coughs after drinking liquids The greatest risk to this client is injury from aspiration. Therefore, this is the client the nurse should address first. The priority referral the nurse should make is to a speech-language pathologist because a client who coughs after drinking liquids is at risk for aspiration. Manifestations of dysphagia include changes in voice tone, coughing, delayed swallowing, pocketing of food, and occasional silent aspiration, which can occur if a client is experiencing a decrease in sensation. A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take? Raise the height of the bed to the level of the nurse's elbows. A nurse is caring for a client who is at risk for pressure ulcer formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences? 30° lateral The 30° lateral position, along with positioning devices, can prevent pressure directly over the client's most vulnerable bony prominences. This position can, however, cause pressure on the shoulder, ankle, anterior iliac spine, and trochanter. Therefore, the nurse should ensure the client's head is midline and supported, rotation of the spine is avoided, and position changes are implemented every 1 to 2 hr A nurse is preparing to administer vancomycin 500 mg by intermittent IV infusion every 6 hr. Available is vancomycin 500 mg in 0.9% sodium chloride 100 mL to infuse over 2 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.) 50 A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse's responsibility regarding the client's advance directives? Ask the client whether he has created advance directives. A nurse is assessing a client who has hypokalemia. Which of the following manifestations should the nurse expect? Decreased bowel sounds Decreased bowel sounds are an indication of hypokalemia because of decreased excitability of cells, resulting in less responsiveness to normal stimuli in nerves and muscles. A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client's risk for ventilator- associated pneumonia? Swab the client's mouth with chlorhexidine solution. A nurse is providing teaching to a client following a thoracentesis. Which of the following actions should the nurse take? Position the client on her unaffected side. The nurse should position the client on the unaffected side to help facilitate expansion of the affected lung A nurse is completing a neurological assessment of an older adult client and notes that the client has become increasingly confused and agitated in the last 48 hr. Which of the following conditions is the priority assessment by the nurse? Infection A nurse is assessing a client who is receiving intermittent catheter irrigation following a transurethral resection of the prostate (TURP). Which of the following manifestations is the priority for the nurse to report to the provider? Increase in bladder spasms A nurse is providing discharge teaching to a client who has heart failure and a new prescription for furosemide. Which of the following foods should the nurse recommend to the client as the best source of potassium? 1 cup cantaloupe A nurse is preparing to administer an opioid medication to a client who is experiencing pain. Which of the following actions should the nurse take? Ask a second nurse to witness the discarding of unused opioid medication. The nurse should ask a second nurse to witness the discarding of unused opioid medication and sign the designated form. A nurse is providing discharge teaching to a client who is prescribed home oxygen therapy using a compressed oxygen system. Which of the following statements by the client indicates to the nurse that the teaching has been effective? "I will store oxygen tanks in an upright position." This statement by the client indicates an understanding of the teaching. The nurse should instruct the client to store oxygen tanks in an upright position in a holder to prevent damage to the tank and injury to the client and the client's family. A school nurse is teaching a group of parents about measures to prevent firearm injuries in the home. Which of the following instructions should the nurse include in the teaching? "Keep ammunition and guns in separate, locked locations." A nurse is performing postmortem care for an older adult client who has just died. Which of the following actions should the nurse take? Identify the client using two identifiers. The nurse should identify the deceased client using two identifiers, such as name and birth date, or name and account number, and then compare the identifiers to the information in the client's medical records. A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the nurse take to maintain the client's skin integrity? Use an alcohol-free barrier product The nurse should apply an alcohol-free barrier film to keep the client's skin dry and protect it from the collection of moisture. This action will help to maintain the integrity of the client's skin. Repostion every 2 hours A nurse is preparing to administer an intramuscular injection to a client. At which of the following angles should the nurse insert the needle? 90° The nurse should plan to insert the needle at a 90° angle when administering medication via the intramuscular route. The intramuscular route promotes quicker medication absorption into the muscle than the other routes of medication administration. 45 60 degree- sub q 15 degree- intradermal A nurse is providing teaching to an older adult client who has kyphosis and osteoporosis. Which of the following statements by the client indicates to the nurse that the teaching has been effective? "I will increase daily intake of calcium and vitamin D." A nurse is assessing a client who has an NG tube with continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the nurse take next? Position the client on her side. The greatest risk to this client is aspiration from possible dislodgment of the NG tube and aspirated stomach contents into the respiratory tract. Therefore, the priority nursing action to decrease exacerbation of the condition is to position the client on their side. A nurse is caring for a client who is receiving intermittent enteral feedings via gastrostomy tube (G-tube). Which of the following actions should the nurse take when administering the feeding? Pour the client's formula into the syringe, raising or lowering it to control the rate of flow. A nurse is caring for a client who is recovering from a bronchoscopy. Select the area the nurse should assess before giving the client ice chips or fluids. (You will find "hot spots" to select in the artwork below. Select only the hot spot that corresponds to your answer.) A nurse is providing teaching about cough etiquette to a client who has influenza. Which of the following instructions should the nurse include in the teaching? Cover your nose and mouth with a tissue when coughing." The nurse should instruct the client to cover their nose and mouth with a tissue when coughing. The client should discard the tissue promptly in the nearest trash container. A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client's tube? (Select all that apply.) Examine the color of aspirated secretions. Measure the pH of the client's aspirate. Obtain an x-ray of the client's chest and abdomen. Measure the amount of aspirate in the NG tube is incorrect. The nurse should measure the amount of aspirate in the NG tube when the client is receiving tube feedings to evaluate absorption. However, measuring the aspirate in the NG tube does not confirm placement. Placement of the NG tube must be confirmed prior to initiating feedings. Flush the tube with 50 mL of tap water is incorrect. The nurse should not instill fluid into an enteral tube until placement is confirmed. Examine the color of aspirated secretions is correct. Gastric secretions are typically cloudy, green, or tan in color. Intestinal secretions are bile-stained and therefore, typically appear yellow in color. Measure the pH of the client's aspirate is correct. Stomach contents are usually acidic, with a pH less than 5.5. A pH of 6 is an indication that the distal end of the tube is located in the intestines. A pH above 7 is an indication that the distal end of the tube is located in the respiratory tract. Obtain an x-ray of the client's chest and abdomen is correct. Radiological examination is the most reliable method of verifying the placement of a client's NG tube. A nurse is reviewing data in a client's medical record. Which of the following pieces of information should the nurse expect to find in the nurses' notes? The client's ability to cope with a new illness A nurse is caring for a client who has a stressful job and reports a decrease in quality of sleep. Which of the following actions should the nurse take to assist the client to manage her stress effectively? Help the client identify what triggers her stress. A nurse is caring for a client who has a terminal illness. The client requests a do-not-resuscitate (DNR) status, but her family is opposing her decision. Which of the following actions should the nurse take first? Gather information to support the client's need for DNR status Using the nursing process, the first action the nurse should take is to assess the situation by gathering information to support the client's request for a DNR order. This information should include the client's current clinical status, factors such as the client's spirituality, culture, and family dynamics, and evidence from literature about the client's condition. A nurse is assessing a client's coping skills. Which of the following client stressors should the nurse identify as internal? Nutritional status Fear of medical test results MY ANSWER Fear of medical test results is an internal stressor that originates within the body and mind of a client. Internal stressors are pressures that the client places upon themselves and are often the most common causes of stress. These stressors often force clients to deal with conflicting inner values and interactions with others. When a client manages internal stressors, it enhances their ability to deal with external stressors. A nurse is teaching pursed-lip breathing to a client who has COPD. Which of the following instructions should the nurse include in the teaching? "Exhale slowly through your mouth." A nurse is caring for a client who has a new onset of type 1 diabetes mellitus. The client has expressed feelings of hopelessness about managing the disease. Which of the following interventions should the nurse use first to encourage the client's efforts to manage the disease? Exploring the client's past coping mechanisms The first action the nurse should take when using the nursing process is to assess the methods that the client used to successfully cope with other issues in the past and then reinforce them. This will help encourage the client to begin to learn self-care. A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take? Move the client using an air-assisted transfer device. The nurse should place an air-assisted device under the client prior to transfers to prevent injury. An air- assisted transfer device is an inflatable mattress that minimizes friction to smoothly and efficiently move the client from the bed to the stretcher. In addition, at least two caregivers should assist with the transfer of a client who weighs 136 kg (300 lb). A home health care nurse is conducting a fall risk assessment for an older adult client who lives alone. The nurse should identify which of the following factors as creating a significant risk for falls? The client owning a small dog

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