VATI Fundamentals Practice Guide Questions And Well Elaborated Answers.

A nurse is preparing to mix short acting and intermediate acting insulin in one syringe to administer to a client who has type 1 diabetes mellitus. Identify the sequence the nurse should follow - correct answer To mix insulin from two vials in the same syringe, the nurse should first draw up a volume of air equal to the volume of insulin from the intermediate-acting insulin vial. The nurse should then inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting insulin vial, making sure the needle does not touch the insulin. Next, the nurse should inject the volume of air equal to the insulin dose from the short-acting insulin vial. Then, the nurse should withdraw the prescribed amount of insulin from the short-acting insulin vial. Lastly, the nurse should withdraw the prescribed amount of insulin from the intermediate-acting insulin vial. The insulins are now mixed and ready to administer. A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy utilizing a compressed oxygen system. Which of the following statements by the client indicates an understanding of the teaching - correct answer "I will store my oxygen tanks in an upright position" This statement by the client indicates an understanding of the teaching. The nurse should instruct the client to store oxygen tanks in an upright position in a holder to prevent damage to the tank and injury to the client and the client's family. A nurse is evaluating preoperative teaching with a client who is to undergo surgery with general anesthesia. Which of the following statements by the client indicates an understanding of the teaching? - correct answer "I should remove nail polish from my fingers before surgery The nurse should instruct the client to remove nail polish for accurate pulse oximetry monitoring and for a clear view of the nail beds when assessing capillary refill. A nurse is providing teaching about cough etiquette to a client who has influenza. Which of the following instructions should the nurse include in the teaching? - correct answer "Cover your mouth and nose with a tissue when coughing" The nurse should instruct the client to cover their nose and mouth with a tissue when coughing. The client should discard the tissue promptly in the nearest trash container A nurse is planning care for a client who has a history of seizures. Which of the following interventions should the nurse include in the plan of care? - correct answer Ensure oral suction equipment is at the bedside; to prevent aspiration of oral secretions during seizure A nurse is assessing an older adult client who has become increasingly confused and agitated in the last 48 hrs. Which of the following conditions should the nurse expect? - correct answer UTI According to EBP, the RN should expect the client who has a UTI to become increasingly confused and agitated. Confusion and agitation in older adult clients often result from a systemic infection, such as a UTI or pneumonia A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which of the following actions should the nurse take next? - correct answer Turn client onto side The greatest risk to this client is aspiration from possible dislodgment of the NG tube and aspirated stomach contents into the respiratory tract. A nurse is assessing a client for hearing acuity by performing the Rinne Test. Which of the following actions should the nurse take? - correct answer Move a vibrating tuning fork's prongs in front of the client's left or right ear canal. The nurse should perform the Rinne test by placing the handle of a vibrating tuning fork on the client's mastoid process and then moving the vibrating prongs 1 to 2 cm (0.4 to 0.8 in) in front of the client's left or right ear canal. The Rinne test compares bone conduction with air conduction. The client is expected to hear sound conduction by air for twice as long as bone conduction. A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the nurse take to maintain the client's skin integrity? - correct answer Apply an alcohol free barrier product; to keep the pt's skin dry and protect it from the collection of moisture. This action will help to maintain the integrity of the pt's skin A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care? (SATA) - correct answer Notify ancillary departments of the client's allergy Label the surgical suite as latex-free Ensure latex allergy cart is available A nurse is preparing to transfer a pt who weighs 136 kg/300 lb from a bed to a stretcher with the aid of an AP. Which of the following actions should the nurse take? - correct answer Use an air-assisted transfer device to move the client. The nurse should place an air-assisted device under the client prior to transfers to prevent injury. An air-assisted transfer device is an inflatable mattress that minimizes friction to smoothly and efficiently move the client from the bed to the stretcher. In addition, at least two caregivers should assist with the transfer of a client who weighs 136 kg (300 lb). A home health nurse is performing a home assessment for an older adult client. which of the following statements by the client should alert the nurse to suggesst additional safety measures? - correct answer ""I use space heaters to keep warm in the winter" A common environmental hazard in the home is the use of space heaters, which can increase the risk of fire. A RN is caring for a client who has terminal illness. The client request a DNR order, but their family opposes the decision. Which of the following actions should the nurse take first.? - correct answer Gather information to support the client's request for a DNR Using the nursing process, the first action the nurse should take is to assess the situation by gathering information to support the client's request for a DNR order. This information should include the client's current clinical status, factors such as the client's spirituality, culture, and family dynamics, and evidence from literature about the client's condition. A school RN is teaching a group of parents about measures to prevent firearm injuries in the home. Which of the following instructions should the nurse include in the teaching? - correct answer "Keep ammunition and guns in seperate, locked locations." The nurse should instruct the parents to keep ammunition in a locked cabinet separate from the firearms to reduce the risk for injury. This action will prevent access to the firearm and also prevents injury from accidental discharge because the firearm does not contain ammunition. Also, the keys to the cabinet should not be accessible to children. A nurse is preparing to delegate task for multiple clients at the beginning of the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? - correct answer Assist a client with ambulation When delegating client care activities to an AP, the delegating nurse should follow the five rights of delegation, which include right task, right circumstance, right person, right direction, and right evaluation. Assisting a client with ambulation is within the range of function of an AP A home health nurse is teaching about oral care to the family of a client who is in a coma. Which of the following task should the nurse instruct the family to perform first? - correct answer Place the pt in a side lying position. The greatest risk to this client is injury from aspiration. Therefore, the first action the nurse should instruct the family to perform is to place the client in a side-lying position. If the client should not be placed in a side-lying position, then the nurse should instruct the family to turn the client's head to the side to allow fluid to run out of the client's mouth A nurse is admitting a client who is to undergo a surgical procedure. Underlying the Patient Self-determination act (PSDA) which of the following actions is the nurse's responsibility regarding the pts advance directives? - correct answer Ask the client if they have created advance directives. The PSDA requires facilities to provide information to clients about their rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. Under the act, staff should ask the client if they have advance directives, and the nurse should document the client's response in the medical record. A RN is preparing to administer opthalmic drops to a client. Which of the following actions should the nurse take? - correct answer The nurse should rest the dominant hand on the client's forehead while instilling the drops. This action stabilizes the nurse's hand and ensures that the hand will move with the client if they move suddenly. This simple precaution reduces the risk of striking the client's eye with the dropper and injuring it. A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse take prior to performing the teaching? (SATA) - correct answer - Establish the client's learning needs- Determine the client's literacy level- Evaluate the client's readiness for learning- Identify the client's learning style a RN is caring for a client who has suspected Clonus. which action will assess the client for the condition - correct answer Use a reflex hammer The nurse should use a reflex hammer to assess the client for clonus. The reflex hammer causes the muscle to immediately contract due to a two-neuron reflex arc involving the spinal or brainstem segment that innervates the muscle. A nurse is performing postmortem care for an older client who had just died. Which of the following actions should the nurse take? - correct answer identify the client using two identifyers