Vernon Russell vSIM 2023 Exam Questions And Answers All Correct

Vernon Russell vSIM 2023 Exam Questions And Answers All Correct Mr. Russell has been placed on fall precautions. what actions should the nurse take to keep the patient safe? (select all that apply) a. provide non-skid socks for ambulation b. instruct patient to call for assistance when out of bed c. place the call bell within reach d. maintain be in low position at all times e. keep side rails up x4 at all times - CORRECT ANSWERS a. provide non-skid socks for ambulation b. instruct patient to call for assistance when out of bed c. place the call bell within reach d. maintain be in low position at all times a patient has been admitted with a diagnosis of stroke, and the nurse has received orders to hold warfarin until lab results are received. what lab results does the nurse anticipate reviewing prior to administering this medication? a. platelets b. d-dimer c. hemoglobin and hematocrit d. PT/INR - CORRECT ANSWERS d. PT/INR the nurse is caring for a patient who has experienced a sudden change in level of consciousness and has difficulty speaking. what is the priority action of the nurse? a. notify the charge nurse b. assess the patent c. document the findings d. wait 15 minutes to see if the problem resolves - CORRECT ANSWERS b. assess the patent Mr. Russell experienced dysphagia and mild left-sided weakness following his stroke. for which additional symptoms of stroke should the nurse assess? (select all that apply) a. urinary incontinence b. communication difficulties c. hearing loss d. sensory deficits e. decreased peristalsis - CORRECT ANSWERS a. urinary incontinence b. communication difficulties d. sensory deficits the nurse is assessing a patient using the Glasgow Coma Scale. which of the following are components of that scale? (select all that apply) a. motor response b. eye opening c. respiration d. brain stem reflexes e. verbal response - CORRECT ANSWERS a. motor response b. eye opening e. verbal response Mr. Russell has an order for vital signs and neurochecks every four hours. which assessment findings, if made by the nurse, would indicate potential neurologic compromise? (select all that apply.) a. unequal pupils b. left-sided weakness c. decreasing level of consciousness d. difficulty swallowing e. unsteady gait - CORRECT ANSWERS a. unequal pupils c. decreasing level of consciousness the nurse is caring for a stroke patient with mild dysphagia. what would be an appropriate nursing intervention for this patient in order to minimize risk for injury? (select all that apply.) a. providing mouth care immediately before meals b. placing food in an easily accessible position c. educating the patient about the importance of alternating liquids and solids d. providing a 30-minute rest period prior to mealtimes e. positioning patient upright in chair if not contraindicated - CORRECT ANSWERS c. educating the patient about the importance of alternating liquids and solids d. providing a 30-minute rest period prior to mealtimes e. positioning patient upright in chair if not contraindicated Mr. Russell is being discharged from the hospital following a mild stroke. what instruction would the nurse include in discharge education? a. you only need to take your medication when symptoms are present b. it is important that you begin smoking cessation program c. be sure to weigh yourself at the same time each day d. a low-protein diet is necessary to maintain your heath - CORRECT ANSWERS b. it is important that you begin smoking cessation program the nurse is calling in report to the provider using the SBAR format. Which statement by the nurse would by the "S" when using this reproting technique? a. the patients lungs are clear to auscultation b. the patient was admitted with stroke and mild left hemiplegia c. the patient began coughing when eating breakfast this morning d. i recommend the patient be sent for a swallow study - CORRECT ANSWERS c. the patient began coughing when eating breakfast this morning the nurse is recording fluid intake for Ms. Johnson. which items on the dinner tray should the nurse include when completing this documentation? (select all that apply.) a. iced yea b. tomato soup c. ice cream d. applesauce e. creamed corn - CORRECT ANSWERS a. iced yea b. tomato soup c. ice cream the nurse is preparing to insert an intermittent urinary catheter in a paralyzed female patient. what would be the appropriate action by the nurse? a. call for a co-worker to help the patients legs in position b. ask a family member to assist you with the catheterization c. notify the provider that the procedure could not be completed because the patient is paralyzed d. instruct the patient to turn over on her side - CORRECT ANSWERS a. call for a co-worker to help the patients legs in position the nurse has created a sterile field and is preparing to catheterize a patient. while using sterile cotton balls to clean the patient prior to the procedure, the nurse drops a contaminated cotton ball in the middle of the sterile field. what is the correct action of the nurse at this time? a. remove the contaminated cotton ball from the field with the non-dominant hand b. continue with the procedure while avoiding the contaminated cotton ball c. obtain a new catheter kit and restart the procedure d. ask a co-worker to remove the contaminated cotton ball from the field - CORRECT ANSWERS c. obtain a new catheter kit and restart the procedure the nurse has received an order to collect a urine sample. which characteristics would the nurse observe for when assessing the patients specimen? (select all that apply) a. odor b. sediment c. color d. pH e. clarity - CORRECT ANSWERS a. odor b. sediment c. color e. clarity