Fundamentals VATI Questions and Answers

Fundamentals VATI Questions and Answers A nurse is reinforcing teaching with a client about living wills. Which of the following client statements indicates an understanding of the teaching? "The living will directs my medical care when I am unable to make decisions. " A nurse is reinforcing preoperative teaching with a client who speaks a different language than the nurse. Which of the following actions should the nurse take? Provide handouts written in the client's primary language. A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse? "When I look at myself in the mirror, I don't know if I can go on." A nurse is caring for a post-op client who is at risk for thrombus formation. Which of the following interventions should the nurse delegate to an assistive personnel (AP)? Apply thromboembolic stockings. A nurse is contributing to the plan of care for a client who has a positive throat culture for streptococci. Which of the following interventions should the nurse recommend to be included in the plan of care? Ensure that the client wears surgical mask during transportation throughout the facility. A nurse is speaking with a client who has type 2 diabetes mellitus and a prescription for insulin. The client verbalizes anger about having to take insulin. Which of the following responses should the nurse make? "I see that you are angry. Let's sit down and talk." A nurse is calculating the intake and output for a client over the last 8hr. The client is receiving a continuous IV infusion at 150mL/hr and had 4 oz of juice and 0.5L of water. How many mL of fluid should the nurse document as the client's intake for the last 8 hr? 1820mL A nurse is reinforcing teaching with a client about the prevention of stress injuries. Which of the following instructions should the nurse include? "When lifting a heavy object, keep it close to your body." A nurse is caring for a client who is refusing medical treatment. Which of the following actions should the nurse take? Document the client's refusal of the treatment. A nurse is reinforcing teaching with a client who has a partial hearing loss about how to modify the home environment. Which of the following is priority modification that the nurse should include? Flashing smoke alarm A nurse is repositioning a client who has quadriplegia and is in the supine position. Which of the following actions should the nurse take to prevent client musculoskeletal injury? Internally rotate the client's hips by using trochanter roll. A nurse is assisting with the care of a recently deceased client. Which of the following actions should the nurse complete prior to the family viewing the body? Clean soiled areas of the body. A nurse is reinforcing pre-op teaching with a client about how to turn, cough, and deep breathe. Which of the following statements by the client indicates an understanding of the teaching? "This can help prevent pneumonia." A nurse is preparing to administer an enteral feeding to a client who has an NG tube in place. Which of the following ,methods should the nurse use to verify correct placement of the NG tube? Check the pH of the gastric aspirate. A nurse is preparing to remove a client's peripheral IV catheter. After performing hand hygiene and applying clean gloves, which of the following actions should the nurse take first? Clamp the infusion tubing. A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan? Pad bony prominences on the wrists. A nurse is planning to perform wound irrigation for a client who has a large abdominal wound. Which of the following actions should the nurse plan to take? Administer an analgesic 30 min before starting the procedure. A nurse is preparing to collect data from a client for a health assessment. Which of the following actions should the nurse take? Provide privacy for the client. A nurse is reinforcing teaching about health promotion with a group of young adult clients. Which of the following information should the nurse include? Young adults should receive a dental assessment every 6 months. A nurse is reinforcing teaching with a client about the use of crutches. Which of the following actions by the client indicate an understanding of the teaching? The client advances the unaffected leg first while climbing the stairs. A nurse is collecting data from an older adult client. Which of the following findings should the nurse report to the provider? The client reports urinary incontinence. A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching? "I will be sure to keep the crutch tips dry." A nurse is moving a client up in bed with the assistance of a second nurse. Which of the following actions should the nurse take? Place feet apart with the foot nearest the head of the client's bed in front of the other foot. A nurse is caring for a client who has terminal illness has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make? "The reduced muscle tone has relaxed the jaw muscles." A nurse is assisting with the admission of a client who has brought their medications to the facility. Which of the following actions should the nurse take? Compare the medications the provider has prescribed with the client's medications from home. A nurse is preparing to administer oxygen to a client who has heart failure and is having severe difficulty breathing. Which of the following oxygen delivery equipment should the nurse select to provide the highest concentration of oxygen to the client? Nonrebreather mask A client who has advanced cancer tells the nurse that they have a difficult time talking to anyone about the illness. Which of the following actions should the nurse take to encourage therapeutic communication? Let the client know that, as their nurse, they are available and willing to listen. A nurse is caring for four clients who are required to provide informed consent for treatment. The nurse should identify that which of the following clients is able to provide informed consent? An 18yr old client who has acute appendicitis. A nurse is collecting data on four clients. Which of the following findings should the nurse report to the provider? Urine output of 200mL over 8 hr. A nurse is assisting with the admission of a client who has active tuberculosis. Which of the following actions should the nurse plan to take? Assign the client to a negative-pressure airflow room. A nurse is using Maslow's hierarchy of need in assisting with discharge planning for a client. Which of the following activities should the nurse recommend as the priority for this client? Attend an exercise program. A nurse is caring for a client who has just died and practiced the Islamic faith. Which of the following cultural practices should the nurse expect? The client's face should be turned toward Mecca. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that allowing a client to make a decision about treatment is an example of which of the following ethical principles? Autonomy A nurse is reinforcing teaching with a client about smoking cessation. Which of the following should the nurse identify as the first stage of health behavior change? Precontemplation A nurse is collecting data from a client who has an NG tube set to low intermittent suction. Which of the following findings indicate hypomagnesemia? Positive Chvostek's Sign A nurse is assisting with the plan of care for a client who has aphasia following a stroke. Which of the following interventions should the nurse use to assist the client with communication? Ask the client close-ended questions. A nurse is reviewing the medical record of a client who has heart failure. The nurse should identify which of the following lab results as an indication that the client has fluid volume excess? BUN 8 mg/dL A charge nurse is reinforcing teaching with an assistive personnel (AP) about performing pulse oximetry. Which of the following information should the nurse include in the teaching? Remove polish from the client's fingernail before applying the oximetry probe. A nurse at a long-term care facility is caring for a client who is alert. Which of the following actions should the nurse take to protect the client's privacy? Speak with the client about their condition after visitors have left. A charge nurse smells smoke, enters the visitor restroom, and sees flames in the trash can. What is the sequence of actions that the nurse should take? - Evacuate clients from the area. - Pull the lever on the fire alarm box. - Close the fire doors on the unit. - Use a fire extinguisher to put out the fire. A nurse is reinforcing dietary teaching with a client who has chronic kidney disease and requires a low-potassium diet. Which of the following food choices by the client demonstrates an understanding of the teaching? 1 cup of applesauce A nurse is reviewing the VS of four adults clients. Which of the following findings require further data collection by the nurse? A client who has a pulse rate of 110/min. A nurse is assisting with the plan of care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)? Assist a client to get out of bed after a breathing treatment. A nurse is assisting with a presentation to a group of older adults at a community center about hypothermia and hyperthermia. Which of the following information should the nurse include about age-related changes? Circulation becomes less efficient with age. A nurse is caring for a client who is post-op and is experiencing nausea and vomiting. The nurse should identify which of the following findings as indications that the client has fluid volume deficit? - Cool extremities - Orthostatic hypotension - Flat neck veins A nurse is caring for a client who has a prescription for a potassium supplement. The client tells the nurse that the pill is too large to swallow and refuses to take it. The nurse offers to break the pill into two smaller pieces. The nurse is demonstrating which of the following ethical principles? Beneficence A nurse is preparing to palpate a client's pulse. The nurse should recognize that which of the following pulses is located on the top of the client's foot? Dorsalis pedis A nurse is contributing to the plan of care for a client who has a prescription for elastic bandages to the lower extremities. Which of the following actions should the nurse recommend for the plan of care? Compare the client's pedal pulses bilaterally every 4hr. A nurse is preparing to transfer a client from an acute care facility to a long-term care facility. Which of the following information should the nurse plan to include in the transfer report? Resolved health conditions A nurse is taking notes of client information on a piece of paper while receiving report. Which of the following actions should the nurse take to dispose of the paper? Shred the paper in a score container. A nurse is preparing to administer a topical medication to a client. Which of the following actions should the nurse take? Compare the label of the medication container with the medication administration record three times. A nurse has delegated various client care tasks to the assistive personnel (AP) on the care team. Which of the following actions by the AP should the nurse identify as correct? Donning a mask to measure the vital signs of a client who has pertussis. A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent urinary tract infections? Drain urine from the tubing before ambulation. A nurse is caring for a client who has metastatic cancer and practices Catholicism. The client asks the nurse to discuss the afterlife with them. Which of the following statements by the nurse assists in meeting the client's spiritual needs? "Tell me what the afterlife means to you." A nurse is evaluating the crutch-walking technique of a client who is required to keep weight off their right leg. Which of the following is the proper crutch gait for this client? Three-point A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed? "Tighten your stomach muscles." A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? Clean the perineal area at least once a day. A nurse is contributing to the plan of care for a client who practices Islam. Which of the following questions should the nurse ask the client to clarify the client's religious preferences? "Do you consume pork products?" A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure? Headache A nurse is preparing to document information about a client's lower legs, which are swollen with 6mm edema. Which of the following information should the nurse document? 3+ pitting edema A nurse is caring for a client who reports itching 30min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record? Client states, "I started to itch after taking that medication." A nurse is planning care for a group of clients. The nurse should expect to witness an informed consent for a client who will undergo which of the following procedures? Performance of a paracentesis. A nurse is caring for a client who is scheduled for surgery the following day. During the night, the client is unable to sleep and is restless. Which of the following statements should the nurse make? "It must be difficult facing this type of surgery." A nurse is caring for a client who has limited mobility. Which of the following actions should the nurse take to maintain the client's skin integrity? Use warm water when bathing the client. A nurse is caring for a client who reports difficulty sleeping at home. Which of the following recommendations should the nurse provide to promote a restful home sleep environment? "Perform muscle relaxation before bedtime." A nurse is caring for four clients. For which of the following clients should the nurse use the therapeutic communication technique of silence? A client who has just experienced the death of their child. A nurse manager is reinforcing teaching with a group of newly licensed nurses about the disclosure of client health information. A nurse can disclose health information without the client's written permission to which of the following entities? A physical therapist who is involved in the client's care. A nurse is preparing a client for a Romberg test. Which of the following statements should the nurse make? "Stand with your feet together and your arms at your sides." A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take? Remove the staple from the skin after both sides are visible. A nurse is providing care to four clients in an acute care setting. The nurse should identify that which of the following clients statements presents an ethical dilemma? "Please don't tell my doctor, but I am taking my partner's oxycodone." A nurse is caring for a group of clients in a long-term care facility. Which of the following actions should the nurse take to prevent health care-associated infections for these clients? - Wash hands after removing gloves. - Use antimicrobial hand gel after refilling a client's water pitcher. - Clean the stethoscope with an antimicrobial wipe after obtaining vital signs. A nurse is collecting data from a client who is 1 day post-op following abdominal surgery. Which of the following findings is the priority for the nurse to report to the provider? The client has tenderness and warmth in their calf. A nurse is reinforcing teaching about advance directives with a client who has end-stage renal disease. Which of the following client statements indicates an understanding of the teaching? "I know that I can change my advance directives if I need to in the future." A nurse is preparing to obtain a client's VS. Which of the following actions should the nurse take when washing their hands? Turn off the faucet with a clean paper towel after drying hands. A nurse is reinforcing teaching with a client about self-administration of ophthalmic drops. Which of the following instructions should the nurse include? "You should cleanse your eye from the inner to the outer edge prior to putting in the drops." A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask? "Have you had small liquid stools?" A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make? "Describe your concerns about sleeping to me." A client who is scheduled to undergo surgery tells the nurse that they do not understand the procedure and are reconsidering their decision to have it. Which of the following actions should the nurse take? Notify the charge nurse of the client's concerns. A nurse is preparing to perform a wound irrigation for a client who has a stage 3 pressure injury. Which of the following supplies should the nurse plan to use? A piston syringe A nurse is planning to perform intermittent urinary catheterization for a client who is unable to urinate. Which of the following actions should the nurse take first? Perform a bladder scan A nurse is checking a client for a pulse deficit after detecting an irregular heart rate. Which of the following actions should the nurse take? Count the client's radial and apical pulses simultaneously with another nurse. A nurse is providing oral hygiene for a client who is unconscious. Identify the sequence of the steps the nurse should take. - Assess the client's gag reflex - Position the client on their side with their head turned to the side. - Place a towel under the client's head with an emesis basin under their chin. - Separate the client's upper and lower teeth with an oral airway device. - Cleanse the client's mouth using a toothbrush. A nurse is contributing to the plan of care for a client who is at risk for developing foot drop due to immobility. Which of the following interventions should the nurse recommend to include in the plan? Support the client's feet with foot boots. A nurse is assisting with the admission of a client to a med-surg unit. Which of the following findings should the nurse identify as an indication that the client is malnourished? Pallor with scaly skin A nurse is caring for a client who has chronic kidney disease. The nurse should identify that which of the following findings is the priority to report to the provider? The client's output was 60 mL for the past 3hr. A nurse is caring for a client who is post-op following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following? Actual loss A nurse is caring for a client who has a new prescription for O2 at 7L/min via simple face mask. Which of the following actions should the nurse take to ensure client safety? Attach a humidifier to the base of the flow meter. A nurse is reinforcing teaching about carbohydrate counting with a client who has a new diagnosis of diabetes mellitus. Which of following actions should the nurse take first? Ask the client what they already know about meal planning. A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take? Choose a private room for the interview. A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their BP daily. Which of the following client statements indicate an understanding of the teaching? "I should remove constrictive clothing prior to measuring my BP." A nurse is caring for a client who has dysphagia following a stroke. Which of the following interventions should the nurse use when feeding the client? Instruct the client to tilt their head forward while eating.