VATI: Medical-Surgical Alternate Item Format Quiz practice exam questions and answers 2024

A charge nurse is delegating a task. The nurse understands which of the following represents effective delegation? Select all that apply. Select one or more: a. Asking the nurse if they are capable of completing the delegated task. b. Delineating the desired outcomes of the delegation. c. Referring to the ANA Code of Ethics for effective delegation practices. d. Monitoring how the delegated task is being accomplished. e. Delegating a task that should be assigned to a manager. a. Asking the nurse if they are capable of completing the delegated task. b. Delineating the desired outcomes of the delegation. d. Monitoring how the delegated task is being accomplished. - Asking the individual who is being delegated if they are capable of completing the delegated task is considered effective delegating. Identifying the qualified person best able to complete the job in terms of capability and time to do so is considered effective delegation. - Effective delegation means planning ahead when identifying tasks to be accomplished. Assess the situation, and clearly delineate the desired outcomes. - Monitoring how the task is being accomplished is considered effective delegating. A nurse is aware that priorities need to be continuously set and reset in order to meet the needs of multiple clients. Which principles of client care should the nurse use for prioritization when giving report? Select all that apply. Select one or more: a. Prioritize systemic before local. b. Prioritize potential problems before actual. c. Prioritize acute before chronic. d. Recognize and respond to transient findings. e. Listen carefully and don't assume. a. Prioritize systemic before local. c. Prioritize acute before chronic. e. Listen carefully and don't assume. - Prioritizing systemic before local ("life before limb") is a prioritization principle in client care. Examples include prioritizing interventions for a client in shock over interventions for a client with a localized limb injury. - Prioritizing acute (less opportunity for physical adaptation) before chronic (greater opportunity for physical adaptation) is a prioritization principle in client care. Examples include prioritizing the care of a client with a new injury/illness (e.g., mental confusion, chest pain) or an acute exacerbation of a previous illness over the care of a client with a long-term chronic illness. - Listen carefully and don't assume is a prioritization principle used in client care. Recognizing that a postoperative client's report of pain could be due to pain in another location rather than expected surgical pain. A nurse is obtaining a sterile specimen from an indwelling urinary catheter. Place the following steps in the order the nurse should use to obtain this specimen: A. Remover clamp to resume drainage. B. Drain the cathether's tubing of urine. C. Place urine sample in sterile container. D. Clamp the catheter's tubing below port for 20 minutes. E. Clean the injection port cap of the catheter drainage tubing with antiseptic. F. Attach a sterile syringe to the port and aspirate quantity of urine required. Select one: a. B, D, E, F, C, A b. D, A, C, F, E, B c. A, C, E, D, B, F d. B, E, F, C, A, D a. B, D, E, F, C, A Draining urine from the tubing and then clamping allows urine to collect in the tubing so a fresh specimen is obtained. Aseptic technique should be maintained during procedure and cleansing port with an appropriate antiseptic solution will remove surface contaminates. Use of a sterile syringe and container is necessary to prevent contamination of specimen. Removing clamp after the procedure allows for continued urine drainage. A nurse is caring for a client with a tracheostomy. In which order should the following interventions be performed when providing tracheostomy care? A. Document the type and amount of secretions. B. Suction the tracheostomy. C. Clean the inner cannula with hydrogen peroxide followed by sterile saline. D. Apply an oxygen source loosely to prevent desaturation. E. Change tracheostomy ties if soiled. F. Apply a split 4X4 dressing around the tracheostomy. Select one: a. B, D, C, F, E, A b. B, C, D, F, A, E c. C, B, D, A, F, E d. A, B, D, E, F, C a. B, D, C, F, E, A Rationale: B. Suction the tracheostomy tube, if necessary, using sterile suctioning supplies. D. Apply the oxygen source loosely if the client's SaO2 decreases during the procedure. Use surgical asepsis to remove and clean the inner cannula with ½ strength hydrogen peroxide and rinse it with a sterile saline solution. C. Clean the stoma site and the tracheostomy plate with ½ strength hydrogen peroxide followed by sterile saline. F. Place a split 4X4 dressing around the tracheostomy. E. Change ties if they are soiled. A. Document the type and amount of secretions, the general condition of the stoma and surrounding skin, the client's response to the procedure, and any teaching or learning that took occurred. A nurse is educating a client about implementation of bowel training program. Which of the following interventions should be included in the plan of care? Select all that apply. Select one or more: a. Drink hot milk before defecation time. b. Avoid the use of time limits for defecation. c. Choose a regular toileting time based on the client's pattern. Correct d. Take stool softeners daily. e. Advise the client to lean forward at the hips while sitting on the toilet. c. Choose a regular toileting time based on the client's pattern. Correct d. Take stool softeners daily. e. Advise the client to lean forward at the hips while sitting on the toilet. - Choosing a time in the client's pattern to initiate defecation control measures is appropriate. Clients can be encouraged to sit on the toilet about 30 minutes after a meal, whether or not they feel the urge to defecate. - Giving stool softeners orally every day or a cathartic suppository at least half an hour before the selected defecation time can assist with bowel training. - Instructing the client to lean forward at the hips while sitting on the toilet, to apply manual pressure with the hands over the abdomen, and to bear down but not strain can assist with stimulating colon emptying. A nurse is caring for a client who has difficulty swallowing following a cerebrovascular accident (CVA). Which of the following interventions should the nurse implement? Select all that apply. Select one or more: a. Encourage client to flex head and neck back when swallowing. b. Encourage client to place food in the front of the mouth. c. Elevate the head of the bed 90 degrees before feeding. d. Assess swallowing reflexes before feeding. e. Maintain suction equipment at the bedside. c. Elevate the head of the bed 90 degrees before feeding. d. Assess swallowing reflexes before feeding. e. Maintain suction equipment at the bedside. - Elevating the head of the bed 90 degrees will facilitate swallowing and prevent aspiration. - To assist with safe feeding, the nurse should assess the clients swallowing reflexes before feeding. Gag and cough reflexes should also be assessed. - Suction equipment must be maintained at the bedside of client at risk for aspiration to aid in clearing the airway.