REAL VATI PART 1
A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a
hemolytic reaction. Which of the following actions should the nurse perform?
A. Infuse 0.9% sodium chloride IV
B. Administer an antipyretic
C. Decrease the infusion rate to 75 mL/hr
D. Place the client in a left lateral position
infuse 0.9% sodium chloride IV (unless says first , then stop)
A nurse is assessing a client's cardiovascular system. Identify where the nurse
should place the diaphragm of the stethoscope to best hear the closing of the aortic
heart valve. (Selectable areas or Hot Spots" can be found by moving your cursor
over the artwork until the cursor changes appearance, usually into a hand. Click
only on the Hot Spot that corresponds to your answer
option A
A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery
suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which
of the following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam
,C. Prepare the client for a cesarean section
A charge nurse on a pediatric unit is making assignments for a float nurse from the medical
unit. Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect
tomorrow
D. A 14-year-old client who is scheduled for discharge today following
A 10-year-old client who has pneumonia and is receiving respiratory treatments
A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket.
After moving the client to safety, which of the following is the priority action?
A. Notify the facility operator.
B. Close the fire doors on the unit.
C. Turn off oxygen sources.
D. Put out the fire with the appropriate extinguisher.
. Notify the facility operator.
A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
,A. Generalized edema
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse.
Which of the following statements indicates the newly licensed nurse understands the purpose
of the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
. This technique decreases the risk of subcutaneous infiltration
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following
interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes
. Monitor the client for 1 hr after meals
A nurse is planning care for a child who has increased intracranial pressure with a decrease in
level of consciousness. Which of the following interventions should the nurse include in the
plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs
, . Maintain the head at a midline position
A nurse is assessing a client who has delirium due to a febrile illness. Which of the following
findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia
A. Hallucinations
A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse
should identify that which of the following findings indicates fluid overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses
Bounding pulses
A nurse is caring for a client following an open colectomy. Which of the following findings
places the client at risk for delayed wound healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain
Hyperemesis
A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a
hemolytic reaction. Which of the following actions should the nurse perform?
A. Infuse 0.9% sodium chloride IV
B. Administer an antipyretic
C. Decrease the infusion rate to 75 mL/hr
D. Place the client in a left lateral position
infuse 0.9% sodium chloride IV (unless says first , then stop)
A nurse is assessing a client's cardiovascular system. Identify where the nurse
should place the diaphragm of the stethoscope to best hear the closing of the aortic
heart valve. (Selectable areas or Hot Spots" can be found by moving your cursor
over the artwork until the cursor changes appearance, usually into a hand. Click
only on the Hot Spot that corresponds to your answer
option A
A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery
suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which
of the following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam
,C. Prepare the client for a cesarean section
A charge nurse on a pediatric unit is making assignments for a float nurse from the medical
unit. Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect
tomorrow
D. A 14-year-old client who is scheduled for discharge today following
A 10-year-old client who has pneumonia and is receiving respiratory treatments
A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket.
After moving the client to safety, which of the following is the priority action?
A. Notify the facility operator.
B. Close the fire doors on the unit.
C. Turn off oxygen sources.
D. Put out the fire with the appropriate extinguisher.
. Notify the facility operator.
A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
,A. Generalized edema
A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse.
Which of the following statements indicates the newly licensed nurse understands the purpose
of the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
. This technique decreases the risk of subcutaneous infiltration
A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following
interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes
. Monitor the client for 1 hr after meals
A nurse is planning care for a child who has increased intracranial pressure with a decrease in
level of consciousness. Which of the following interventions should the nurse include in the
plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs
, . Maintain the head at a midline position
A nurse is assessing a client who has delirium due to a febrile illness. Which of the following
findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia
A. Hallucinations
A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse
should identify that which of the following findings indicates fluid overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses
Bounding pulses
A nurse is caring for a client following an open colectomy. Which of the following findings
places the client at risk for delayed wound healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
D. Uncontrolled pain
Hyperemesis
