VATI GREEN LIGHT COMPREHENSIVE FORM C
EXAM QUESTIONS AND SOLUTIONS GRADED
A+
◉ A nurse is caring for a client who has cirrhosis of the liver. Which
of the following actions should the nurse take?
A. Monitor for abdominal ascites
B. Implement a low-carbohydrate diet
C. Review serum amylase levels
D. Place warm compresses on area of pruritus
Answer: A. Monitor for abdominal ascites
◉ A nurse is caring for a client who is receiving systematic
desensitization therapy to treat agoraphobia. Which of the following
client statements should indicate to the nurse that the treatment has
been effective?
A. I have been able to watch a church service on television without
anxiety
B. I was able to sit on a park bench for 30 minutes
C. I enjoyed a visit from four of my work friends at my house
D. I had a panic attack when driving by the grocery store
Answer: B. I was able to sit on a park bench for 30 minutes
,◉ A nurse is caring for a client who is receiving a blood transfusion
at 125mL/hr and develops a hemolytic reaction. Which of the
following actions should the nurse perform?
A. Infuse 0.9% sodium chloride IV
B. Administer an antipyretic
C. Decrease the infusion rate to 75 mL/hr
D. Place the client in a left lateral position
Answer: A. Infuse 0.9% sodium chloride IV
◉ A nurse is caring for a client who had a partial laryngectomy and
is receiving continuous enteral feedings at 65mL/hr through a
gastrostomy tube. Which of the following findings requires
immediate intervention by the nurse?
A. The gastric residual volume is 250 mL following 2 hr of infusion
B. The client is lying in a supine position
C. The infusion pump for administering continuous feeding is turned
off
D. The enteral feeding bag and tubing are not dated
Answer: B. The client is lying in a supine position
◉ A nurse in a pediatric unit is caring for a group of clients. For
which of the following diseases should the nurse implement droplet
precautions?
,A. Varicella-zoster
B. Vancomycin-resistant enterococcus
C. Pertussis
D. Rotavirus
Answer: C. Pertussis
◉ A nurse discovers that the wrong dosage of a medication was
given to a client. When determining what action to take, the nurse
should recognize that which of the following ethical principles
should be applied?
A. Utility
B. Paternalism
C. Fidelity
D. Veracity
Answer: D. Veracity
◉ A nurse is providing postoperative teaching to a client who has a
newly-inserted pacemaker. Which of the following statements by the
client indicates that the teaching has been effective?
A. I will use my cell phone on the ear opposite of my pacemaker
B. I can play softball with my family in 3 weeks
C. I should perform arm exercises daily
, D. I will go to my cardiologist's office when the battery needs to be
changed
Answer: A. I will use my cell phone on the ear opposite of my
pacemaker
◉ A nurse is preparing to administer an IV bolus of albumin 5% to a
client who is receiving a continuous IV infusion. After confirming
compatibility, which of the following actions should the nurse take?
A. Use the injection port farthest from the IV catheter insertion site
B. Occlude the IV tubing above the injection port
C. Check for blood return after medication administration
D. Flush the IV tubing with a heparinized solution
Answer: B. Occlude the IV tubing above the injection port
◉ A nurse is caring for a client who is postpartum and has a new
prescription for methylergonovine for vaginal bleeding refractory to
fundal massage and oxytocin. When reviewing the client's medical
history, the nurse should recognize which of the following diagnoses
as a contraindication to the administration of methylergonovine?
A. Diabetes mellitus
B. Hypertension
C. Migraine headaches
D. Hepatitis B
Answer: B. Hypertension
EXAM QUESTIONS AND SOLUTIONS GRADED
A+
◉ A nurse is caring for a client who has cirrhosis of the liver. Which
of the following actions should the nurse take?
A. Monitor for abdominal ascites
B. Implement a low-carbohydrate diet
C. Review serum amylase levels
D. Place warm compresses on area of pruritus
Answer: A. Monitor for abdominal ascites
◉ A nurse is caring for a client who is receiving systematic
desensitization therapy to treat agoraphobia. Which of the following
client statements should indicate to the nurse that the treatment has
been effective?
A. I have been able to watch a church service on television without
anxiety
B. I was able to sit on a park bench for 30 minutes
C. I enjoyed a visit from four of my work friends at my house
D. I had a panic attack when driving by the grocery store
Answer: B. I was able to sit on a park bench for 30 minutes
,◉ A nurse is caring for a client who is receiving a blood transfusion
at 125mL/hr and develops a hemolytic reaction. Which of the
following actions should the nurse perform?
A. Infuse 0.9% sodium chloride IV
B. Administer an antipyretic
C. Decrease the infusion rate to 75 mL/hr
D. Place the client in a left lateral position
Answer: A. Infuse 0.9% sodium chloride IV
◉ A nurse is caring for a client who had a partial laryngectomy and
is receiving continuous enteral feedings at 65mL/hr through a
gastrostomy tube. Which of the following findings requires
immediate intervention by the nurse?
A. The gastric residual volume is 250 mL following 2 hr of infusion
B. The client is lying in a supine position
C. The infusion pump for administering continuous feeding is turned
off
D. The enteral feeding bag and tubing are not dated
Answer: B. The client is lying in a supine position
◉ A nurse in a pediatric unit is caring for a group of clients. For
which of the following diseases should the nurse implement droplet
precautions?
,A. Varicella-zoster
B. Vancomycin-resistant enterococcus
C. Pertussis
D. Rotavirus
Answer: C. Pertussis
◉ A nurse discovers that the wrong dosage of a medication was
given to a client. When determining what action to take, the nurse
should recognize that which of the following ethical principles
should be applied?
A. Utility
B. Paternalism
C. Fidelity
D. Veracity
Answer: D. Veracity
◉ A nurse is providing postoperative teaching to a client who has a
newly-inserted pacemaker. Which of the following statements by the
client indicates that the teaching has been effective?
A. I will use my cell phone on the ear opposite of my pacemaker
B. I can play softball with my family in 3 weeks
C. I should perform arm exercises daily
, D. I will go to my cardiologist's office when the battery needs to be
changed
Answer: A. I will use my cell phone on the ear opposite of my
pacemaker
◉ A nurse is preparing to administer an IV bolus of albumin 5% to a
client who is receiving a continuous IV infusion. After confirming
compatibility, which of the following actions should the nurse take?
A. Use the injection port farthest from the IV catheter insertion site
B. Occlude the IV tubing above the injection port
C. Check for blood return after medication administration
D. Flush the IV tubing with a heparinized solution
Answer: B. Occlude the IV tubing above the injection port
◉ A nurse is caring for a client who is postpartum and has a new
prescription for methylergonovine for vaginal bleeding refractory to
fundal massage and oxytocin. When reviewing the client's medical
history, the nurse should recognize which of the following diagnoses
as a contraindication to the administration of methylergonovine?
A. Diabetes mellitus
B. Hypertension
C. Migraine headaches
D. Hepatitis B
Answer: B. Hypertension
