PN VATI Fundamentals 2020 - Questions, Answers and Rationales

PN VATI Fundamentals 2020 - Questions, Answers and Rationales A nurse is assisting in the plan of care for a client who has a closed-wound drainage system. Which of the following interventions should the nurse include in the plan? Release hand pressure before replacing the drainage plug. Wear surgical gloves when emptying the drainage device. Wipe the port with soap and water before closing the drain. Compress the bulb to re-establish constant low negative pressure. Rationale: The nurse should include in the plan of care to compress the bulb as needed to re-establish a constant low negative pressure that will work as a closed suction to draw secretions into the bulb. Tips: The nurse should include in the plan of care to maintain hand pressure while replacing the drainage plug to create negative pressure, wear clean gloves while emptying the drainage device to prevent contamination of the surgical wound, and wipe the port and plug with an alcohol wipe before closing the drain to decrease the risk for contamination. A nurse is providing change-of-shift report for a client who had a stroke 48 hrs ago. Which of the following information should the nurse include in the report? The client's CT scan results from the emergency department. The client's pupil reaction on admission. The client's physical therapy schedule for the next day. The client's Glasgow coma scale score. Rationale: The nurse should include the client's current physical findings, such as the Glasgow coma scale score, in the change-of-shift report to promote accurate monitoring and safe care. A nurse is caring for a client who is newly diagnosed with diabetes mellitus and needs to learn how to perform a fingerstick blood glucose test. Which of the following members of the health care team can develop a teaching plan for this task? (Select all that apply.) A registered nurse (RN) A licensed practical nurse (LPN) An assistive personnel (AP) A clinical nurse specialist (CNS) A nurse educator Rationale: A registered nurse (RN), is correct because developing a teaching plan is within the scope of practice for the registered nurse. A clinical nurse specialist (CNS), is correct because developing a teaching plan is also within the scope of practice for the clinical nurse specialist and the CNS is and advanced practice nurse who has expertise in a particular clinical area. A Nurse Educator, is correct because developing a teaching plan is within the scope of practice for the nurse educator. A nurse educator is a registered nurse who is prepared to teach in various areas of nursing and patient care. A nurse is caring for a client who is 1 day post operative following an abdominal hysterectomy. The client states, " I am so sad that I can't have any more children." Which of the following is a therapeutic response by the nurse? "This feeling will go away with time." "I am sorry to hear that you feel that way." "You should focus on healing right now." "I will stay with you while we talk some more about this." Rationale: The nurse should remain with the client to listen to their feelings and concerns. This action is a form of active listening and a therapeutic response. A nurse is caring for a client who has a terminal illness. Which of the following is an expected response by a family member during the anger stage of grieving? The family member criticizes care provided by the nurse. The family member changes the subject when the client mentions their illness. The family member expresses grief about the past. The family member talks about how much the client will be missed. Rationale: According to the Kübler-Ross stages of grieving, during the anger stage, a client or family member might direct their anger at others, including members of the health care team or members of their own family. A nurse is collecting data from a client who is receiving a continuous IV infusion of Lactated Ringer's for dehydration. Which of the following findings indicates infiltration of the solution into the subcutaneous area? The vein feels hard upon palpation. Purulent drainage is noted at the IV site. Seepage of fresh blood is visible at the IV insertion location. The area around the infusion site is cool to the touch. Rationale: Swelling, coolness, paleness, and discomfort at the infusion site indicate infiltration. The nurse should stop the infusion and discontinue the IV line. A licensed practical nurse (LPN) is planning care for a group of clients a the beginning of a shift. For which of the following clients should the nurse request a change in assignment? A client who needs a wound culture. A client who needs an indwelling urinary catheter removed. A client who requires evaluation of an established plan of care. A client who requires an intermittent enteral feeding. Rationale: Evaluating an established plan of care for a client requires advanced nursing knowledge and skill and is outside the scope of practice of an LPN. It is within the scope of practice of an LPN to assist in establishing the plan of care for a client. A nurse discovers a fire in the trash can in a client's room. After removing the client from the room, which of the following actions should the nurse take next? Pull the pin on the fire extinguisher. Activate the fire alarm. Turn off oxygen supply in client rooms. Close the client's door. Rationale: The greatest risk to the client and to other clients is injury from the fire; after removing the client from the room, the priority action the nurse should take is to activate the fire alarm. Tip: FOR FIRE SAFETY THINK OF RACE. A nurse is contributing to the plan of care for a client who is receiving continuous enteral nutrition. The client has a prescription for 2,000 calories/day. The high-calorie enteral formula the client is receiving, provides 2 calories/mL. How many mL/hr should the client receive? (Round answer to nearest whole number.) 42 mL/hr. Rationale: Using