MEDSURG VATI ASSESSMENT EXAM 2024 WITH 100% CORRECT ANSWERS

A nurse is assisting with the care of four clients. Which of the following clients is the priority for the nurse to see -A client who has chest tubes and an oxygen Sat of 90% - aclient who has peripheral edema and urinary output of 130 over 4hrs - A client who has a permanent pacemaker with heart rate of 76/min -a client who has pericarditis and temp. 38 c 100.4 - correct answer - A client who has chest tubes and an oxygen Sat 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 collecting data from a client who was admitted with a Glasgow Coma Scale of 3. Which of the following findings should the nurse expect? - Vacalizes sound -Blinks eyes when asked -Follows motor commands -Nonresponsive Commands - correct answer Nonresponsive Commands A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose state. The GCS is a standardized tool that allows for the evaluation of a client's level of consciousness. The test is divided into three sections that evaluate eye opening, motor response, and verbal response. The GCS ranges from a high score of 15 (fully alert) to a low score of 3 (fully comatose).