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VATI Med surg proctored
A nurse examining a client's rhythm strip notices no visible P waves but many small, erratic
spikes throughout the strip, as well as a variable ventricular rate. The nurse should identify and
report this pattern as which of the following dysrhythmias? - ANS-Atrial fibrillation
The nurse should identify that during atrial fibrillation, the atrioventricular node cannot respond
to so many atrial impulses. Therefore, it sends impulses to the ventricles in an erratic way, which
accounts for these characteristics on the client's rhythm strip.
A nurse is administering a tap water enema to a client who has constipation. The client reports
abdominal cramping during instillation of the enema. Which of the following actions should the
nurse take? - ANS-Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the intestinal spasm to pass if
cramping occurs during administration of the enema. Lowering the helght of the enema bag will
decrease the rate the fluid enters the bowel. Tap water enemas consist of 500 ml to 1Lof fluid
that is instilled into the bowel to soften feces. The volume of fluid stimulates peristalsis.
A nurse is assisting a client who is on bed rest to perform isometric exercises. which of the
following actions should the nurse take? - ANS-Instruct the client to tighten and then relax
muscles repeatedly.
The nurse should instruct the client to perform isometric exercises by holding muscles tight for 5
seconds and then relaxing them. This form of exercise inivolves static contraction of a muscle
without any movement of the Joint, Immobility can cause systemic physiologic effects such as
increased heart rate, increased bone demineralization, decreased muscle strength, joint
contractures, and activity intolerance. Isometric exercises increase muscle mass, tone, and
strength while promoting circulation.
A nurse is assisting in the planning of a health education class for a group of older adult clients.
Which of the following recommendations should the nurse include? - ANS-Obtain a
pneumococcal immunization
The pneumococcal immunization should be obtained to prevent pneumonia and is generally
given at or near the age of 65, One dose provides lifelong immunity
A nurse is assisting with the care of a client who has cellulitis and is receiving IV ceftriaxone.
During data collection, the nurse notes the client is flushed and the client reports urticaria. After
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,VATI Med surg proctored.pdf VATI Med surg proctored.pdf VATI Med surg proctored.pdf
stopping the IV infusion, which of the following actions should the nurse take first? - ANS-Check
the client's respirations.
After stopping the IV infusion, the first action the nurse should take when using the airway,
breathing, circulation approach to client care is to count the client's respirations and monitor for
dyspnea because a client experiencing an allergic reaction can progress to anaphylactic shock
and death.
A nurse is assisting with the care of four clients. Which of the following clients is the priority for
the nurse to see? - ANS-A client who has chest tubes and an oxygen saturation of 90%
Using the airway, breathing, and circulation approach to client care, the nurse should determine
that the priority finding is the client's oxygen saturation level, which is below the expected
reference range of 95% to 100%. Therefore, the nurse should attend to this client first.
A nurse is caring for a client who has a foot fracture and requires crutches. Which of the
following actions should the nurse take to ensure client safety? - ANS-Measure the crutches
with two finger widths below the axilla.
The axillary bar on crutches should be measured with two finger widths under the axilla,
Measuring two finger widths below the axilla can reduce the risk for nerve damage.
A nurse is caring for a client who has a new diagnosis of moderate Alzheimer's disease. Which
of the following provider prescriptions should the nurse expect? - ANS-Donepezil 5 mg PO dally
Donepezil is a cholinesterase inhibitor used to treat mild, moderate, and severe Alzheimer's
disease.
A nurse is caring for a client who has burns to the face, neck, and upper chest. The client has
expressed concerns regarding the change to their physical appearance. Which of the following
actions should the nurse take? - ANS-Encourage the client to ask questions about their
treatment
The nurse should assist the client through the grief process by encouraging them to ask
questions and verbalize concerns. Including the client in the treatment plan provides the client
with a sense of control.
A nurse is caring for a client who has deep vein thrombosis. Which of the following actions
should the nurse take to promote venous return? - ANS-Maintain the use of compression
stockings except when bathing the client.
The antiembolic stockings should be removed for short periods (30 to 60 min) when bathing
VATI Med surg proctored VATI Med surg proctored.pdf VATI Med surg proctored.pdf
, VATI Med surg proctored.pdf VATI Med surg proctored.pdf VATI Med surg proctored.pdf
A nurse is caring for a client who has heart failure and a new prescription for furosemide. The
nurse should monitor the client for which of the following adverse effects of the medication? -
ANS-Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing loss. Audiometry
is recommended for clients recelving prolonged IV furosemide.
A nurse is caring for a client who has phantom pain after healing from a below-the-knee
amputation. Which of the following medications should the nurse expect the provider to
prescribe to relieve the client's pain? - ANS-Pregabalin
Pregabalin is an anticonvulsive medication that is an adjuvant medication for treating
neuropathic pain such as phantom limb pain. Typically, with this type of pain, analgesics and
opioids are ineffective.
A nurse is caring for a client who has type 1 diabetes mellitus and has undergone a
below-the-knee amputation. Which of the following is the nighest priority finding? - ANS-Skin
flap of the residual limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is that the skin flap of the residual limb is cool to the touch. The nurse should
immediately report this finding to the provider. The skin flap of the residual limb should be warm
to the touch, indicating adequate tissue perfusion.
A nurse is caring for a client who is experiencing difficulty using utensils to eat following a
stroke. Which of the following referrals should the nurse recommend? - ANS-Occupational
therapist
The nurse should initiate a referral to an occupational therapist to assist the client who has
impaired function to gain the skills for ADLS, including using eating utensils.
A nurse is caring for a client who is receiving bolus enteral feedings and is prescribed digoxin
and furosemide. Which of the following actions should the nurse take? - ANS-Flush the tube
with water before and after each medication
The nurse should flush the tube with at least 15 mL of water before and after each medication to
ensure the client receives the total dose of the medication and to reduce the risk of clogging the
tube.
VATI Med surg proctored VATI Med surg proctored.pdf VATI Med surg proctored.pdf
VATI Med surg proctored
A nurse examining a client's rhythm strip notices no visible P waves but many small, erratic
spikes throughout the strip, as well as a variable ventricular rate. The nurse should identify and
report this pattern as which of the following dysrhythmias? - ANS-Atrial fibrillation
The nurse should identify that during atrial fibrillation, the atrioventricular node cannot respond
to so many atrial impulses. Therefore, it sends impulses to the ventricles in an erratic way, which
accounts for these characteristics on the client's rhythm strip.
A nurse is administering a tap water enema to a client who has constipation. The client reports
abdominal cramping during instillation of the enema. Which of the following actions should the
nurse take? - ANS-Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the intestinal spasm to pass if
cramping occurs during administration of the enema. Lowering the helght of the enema bag will
decrease the rate the fluid enters the bowel. Tap water enemas consist of 500 ml to 1Lof fluid
that is instilled into the bowel to soften feces. The volume of fluid stimulates peristalsis.
A nurse is assisting a client who is on bed rest to perform isometric exercises. which of the
following actions should the nurse take? - ANS-Instruct the client to tighten and then relax
muscles repeatedly.
The nurse should instruct the client to perform isometric exercises by holding muscles tight for 5
seconds and then relaxing them. This form of exercise inivolves static contraction of a muscle
without any movement of the Joint, Immobility can cause systemic physiologic effects such as
increased heart rate, increased bone demineralization, decreased muscle strength, joint
contractures, and activity intolerance. Isometric exercises increase muscle mass, tone, and
strength while promoting circulation.
A nurse is assisting in the planning of a health education class for a group of older adult clients.
Which of the following recommendations should the nurse include? - ANS-Obtain a
pneumococcal immunization
The pneumococcal immunization should be obtained to prevent pneumonia and is generally
given at or near the age of 65, One dose provides lifelong immunity
A nurse is assisting with the care of a client who has cellulitis and is receiving IV ceftriaxone.
During data collection, the nurse notes the client is flushed and the client reports urticaria. After
VATI Med surg proctored VATI Med surg proctored.pdf VATI Med surg proctored.pdf
,VATI Med surg proctored.pdf VATI Med surg proctored.pdf VATI Med surg proctored.pdf
stopping the IV infusion, which of the following actions should the nurse take first? - ANS-Check
the client's respirations.
After stopping the IV infusion, the first action the nurse should take when using the airway,
breathing, circulation approach to client care is to count the client's respirations and monitor for
dyspnea because a client experiencing an allergic reaction can progress to anaphylactic shock
and death.
A nurse is assisting with the care of four clients. Which of the following clients is the priority for
the nurse to see? - ANS-A client who has chest tubes and an oxygen saturation of 90%
Using the airway, breathing, and circulation approach to client care, the nurse should determine
that the priority finding is the client's oxygen saturation level, which is below the expected
reference range of 95% to 100%. Therefore, the nurse should attend to this client first.
A nurse is caring for a client who has a foot fracture and requires crutches. Which of the
following actions should the nurse take to ensure client safety? - ANS-Measure the crutches
with two finger widths below the axilla.
The axillary bar on crutches should be measured with two finger widths under the axilla,
Measuring two finger widths below the axilla can reduce the risk for nerve damage.
A nurse is caring for a client who has a new diagnosis of moderate Alzheimer's disease. Which
of the following provider prescriptions should the nurse expect? - ANS-Donepezil 5 mg PO dally
Donepezil is a cholinesterase inhibitor used to treat mild, moderate, and severe Alzheimer's
disease.
A nurse is caring for a client who has burns to the face, neck, and upper chest. The client has
expressed concerns regarding the change to their physical appearance. Which of the following
actions should the nurse take? - ANS-Encourage the client to ask questions about their
treatment
The nurse should assist the client through the grief process by encouraging them to ask
questions and verbalize concerns. Including the client in the treatment plan provides the client
with a sense of control.
A nurse is caring for a client who has deep vein thrombosis. Which of the following actions
should the nurse take to promote venous return? - ANS-Maintain the use of compression
stockings except when bathing the client.
The antiembolic stockings should be removed for short periods (30 to 60 min) when bathing
VATI Med surg proctored VATI Med surg proctored.pdf VATI Med surg proctored.pdf
, VATI Med surg proctored.pdf VATI Med surg proctored.pdf VATI Med surg proctored.pdf
A nurse is caring for a client who has heart failure and a new prescription for furosemide. The
nurse should monitor the client for which of the following adverse effects of the medication? -
ANS-Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing loss. Audiometry
is recommended for clients recelving prolonged IV furosemide.
A nurse is caring for a client who has phantom pain after healing from a below-the-knee
amputation. Which of the following medications should the nurse expect the provider to
prescribe to relieve the client's pain? - ANS-Pregabalin
Pregabalin is an anticonvulsive medication that is an adjuvant medication for treating
neuropathic pain such as phantom limb pain. Typically, with this type of pain, analgesics and
opioids are ineffective.
A nurse is caring for a client who has type 1 diabetes mellitus and has undergone a
below-the-knee amputation. Which of the following is the nighest priority finding? - ANS-Skin
flap of the residual limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the nurse should determine that
the priority finding is that the skin flap of the residual limb is cool to the touch. The nurse should
immediately report this finding to the provider. The skin flap of the residual limb should be warm
to the touch, indicating adequate tissue perfusion.
A nurse is caring for a client who is experiencing difficulty using utensils to eat following a
stroke. Which of the following referrals should the nurse recommend? - ANS-Occupational
therapist
The nurse should initiate a referral to an occupational therapist to assist the client who has
impaired function to gain the skills for ADLS, including using eating utensils.
A nurse is caring for a client who is receiving bolus enteral feedings and is prescribed digoxin
and furosemide. Which of the following actions should the nurse take? - ANS-Flush the tube
with water before and after each medication
The nurse should flush the tube with at least 15 mL of water before and after each medication to
ensure the client receives the total dose of the medication and to reduce the risk of clogging the
tube.
VATI Med surg proctored VATI Med surg proctored.pdf VATI Med surg proctored.pdf
