A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia pad

RN VATI Fundamentals Assessment Paper

1.A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose? (Use a leading zero if it applies. Do not use a trailing zero. Round the answer to the nearest tenth.)

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RN VATI Fundamentals Assessment Paper

2.A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected clients who have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for which of the following clients?

3.A nurse in a rehabilitation unit is assessing a group of clients who have traumatic brain injuries. The nurse should identify that which of the following clients requires a priority referral?

4.A nurse is assisting a client to medic in bed. Which of the following actions should the nurse take?

5.A nurse is caring for a client who is at risk for pressure ulcer formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client’s bony prominences? RN VATI Fundamentals Assessment Paper

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6.A nurse is preparing to administer vancomycin 500 mg by intermittent IV infusion every 6 hr. Available is vancomycin 500 mg in 0.9% sodium chloride 100 mL to infuse over 2 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if applicable. Do not use a trailing zero.)

7.A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient Self-Determination Act (PSDA), which of the following actions is the nurse’s responsibility regarding the client’s advance directives?

8.A nurse is assessing a client who has hypokalemia. Which of the following manifestations should the nurse expect?

9.A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client’s risk for ventilator-associated pneumonia?

10.A nurse is providing teaching to a client following a thoracentesis. Which of the following actions should the nurse take?

11.A nurse is completing a neurological assessment of an older adult client and notes that the client has become increasingly confused and agitated in the last 48 hr. Which of the following conditions is the priority assessment by the nurse?

12.A nurse is assessing a client who is receiving intermittent catheter irrigation following a transurethral resection of the prostate (TURP). Which of the following manifestations is the priority for the nurse to report to the provider?

13.A nurse is providing discharge teaching to a client who has heart failure and a new prescription for furosemide. Which of the following foods should the nurse recommend to the client as the best source of potassium?

14.A nurse is preparing to administer an opioid medication to a client who is experiencing pain. Which of the following actions should the nurse take? RN VATI Fundamentals Assessment Paper

15.A nurse is providing discharge teaching to a client who is prescribed home oxygen therapy using a compressed oxygen system. Which of the following statements by the client indicates to the nurse that the teaching has been effective?

16.A school nurse 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?

17.A nurse is performing postmortem care for an older adult client who has just died. Which of the following actions should the nurse take?

18.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?

19.A nurse is preparing to administer an intramuscular injection to a client. At which of the following angles should the nurse insert the needle?

20.A nurse is providing teaching to an older adult client who has kyphosis and osteoporosis. Which of the following statements by the client indicates to the nurse that the teaching has been effective?

21.A nurse is assessing a client who has an NG tube with 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?

22.A nurse is caring for a client who is receiving intermittent enteral feedings via gastrostomy tube (G-tube). Which of the following actions should the nurse take when administering the feeding?

23.A nurse is caring for a client who is recovering from a bronchoscopy. Select the area the nurse should assess before giving the client ice chips or fluids. (You will find “hot spots” to select in the artwork below. Select only the hot spot that corresponds to your answer.)

24.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?

25.A nurse is inserting an NG tube for a client who has a new prescription for enteral feedings. Which of the following actions should the nurse take to verify the placement of the client’s tube? (Select all that apply.)

26.A nurse is reviewing data in a client’s CO. Which of the following pieces of information should the nurse expect to find in the nurses’ notes? RN VATI Fundamentals Assessment Paper

27.A nurse is caring for a client who has a stressful job and reports a decrease in quality of sleep. Which of the following actions should the nurse take to assist the client to manage her stress effectively?

28.A nurse is caring for a client who has a terminal illness. The client requests a do-not-resuscitate (DNR) status, but her family is opposing her decision. Which of the following actions should the nurse take first?

29.A nurse is assessing a client’s coping skills. Which of the following client stressors should the nurse identify as internal?

30.A nurse is teaching pursed-lip breathing to a client who has COPD. Which of the following instructions should the nurse include in the teaching?

31.A nurse is caring for a client who has a new onset of type 1 diabetes mellitus. The client has expressed feelings of hopelessness about managing the disease. Which of the following interventions should the nurse use first to encourage the client’s efforts to manage the disease?

32.A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

33.A home health care nurse is conducting a fall risk assessment for an older adult client who lives alone. The nurse should identify which of the following factors as creating a significant risk for falls?

34.A nurse is preparing to administer an IM injection of two medications in the same syringe as a single injection. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.

35.A nurse receives a telephone call from a client’s family member who asks the nurse for an update on the client’s condition. Which of the following actions should the nurse take to maintain the client’s confidentiality?

36.A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

37.A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the following actions should the nurse take?

38.A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia pad. Which of the following actions should the nurse take?

39.A home health nurse is visiting an older adult client. Which of the following statements by the client should alert the nurse to suggest additional safety measures in the client’s home?

40.A nurse manager is teaching a group of newly licensed nurses about vancomycin-resistant enterococci (VRE) infections. Which of the following information should the nurse manager include in the teaching?

41.A nurse is teaching a client who has a move up allergy about items found in the home that can contain latex. Which of the following items place the client at risk for an allergic reaction? (Select all that apply.)

Dishwashing gloves contain latex. Therefore, they place the client at risk for an allergic reaction.

Many forms of carpet contain latex. Therefore, it places the client at risk for an allergic reaction.

Erasers contain latex. Therefore, they place the client at risk for an allergic reaction. RN VATI Fundamentals Assessment Paper

42.A nurse is preparing to teach a group of clients about the effect of smoking cessation on sleep patterns. Which of the following information should the nurse include in the teaching?

43.A nurse is discussing death and dying with a client who has terminal cancer and is at the end of life. The client asks, “Am I really dying?” Which of the following responses should the nurse make?

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44.A nurse is planning teaching to 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? (Select all that apply.)

Prior to planning any teaching session, the nurse should perform a comprehensive assessment of the client’s learning needs. This assessment incorporates information from the client’s history and physical assessment, current health problems, understanding of and compliance with the prescribed treatment plan, and support system.

Knowing the client’s literacy level is an important factor in communicating with the client and in delivering audiovisual presentations and written materials. If the client cannot understand the information the nurse presents, he will not learn.

The nurse should determine the client’s physical readiness (pain control), emotional readiness (acceptance of diagnosis), and cognitive readiness (appropriate level of consciousness).

The nurse can use a variety of teaching methods, such as dialogue, written materials, and role playing. Computer-assisted learning is not a prerequisite.

The best way to learn varies from client to client. Some people learn best by watching a demonstration, while others thrive in a group setting, and others prefer to read information on their own. In a group setting, the nurse should use a variety of styles to accommodate most learners.

45.A nurse is reviewing the medical record for a client who is postoperative and has a prescription for a clear liquid diet. Based on the information in the medical record, which of the following actions should the nurse take first? (Click on the “Exhibit” button below for additional client information. There are three tabs that contain separate categories of data.)

46.A nurse is assessing a client for hearing acuity by performing the Rinne test. Which of the following actions should the nurse take when performing this test?

47.A nurse is providing discharge teaching about bathtub safety to an older adult client. Which of the following statements by the client indicates an understanding of the teaching?

48.A nurse manager is teaching a group of newly licensed nurses about which procedures are within their scope of practice. Which of the following examples should the nurse include in the teaching?

49.A nurse is administering oral care to a client who is unconscious. Which of the following actions is the nurse’s priority to ensure client safety? RN VATI Fundamentals Assessment Paper

50.A nurse is preparing to notify the provider about a change in a client’s status. Which of the following information should the nurse plan to include in the background portion of the Situation, Background, Assessment, Recommendation (SBAR) communication tool?

51.A nurse is caring for a client who is pulling at his abdominal wound drains. The provider prescribes wrist restraints for the client’s safety. To which of the following parts of the bed should the nurse secure the restraints?

52.A nurse in the surgical department is completing a preadmission interview with a client who is to undergo surgery the next day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client’s surgery? (Select all that apply.)

A client who is allergic to latex should be the first case of the day in the surgical department. This allows overnight removal of latex dust from the previous day.

Notifying ancillary departments of the client’s sensitivity to latex allows the staff to take appropriate measures to ensure medications and surgical items are not contaminated by latex.

This helps keep personnel from bringing rubber products into the room.

Powder from products containing latex can transmit allergens from the hands of health care personnel to the client.

A latex allergy cart should be kept in the operating room at all times. All of the contents must be latex free.

53.A nurse is planning care for a client who is receiving an IV fluid infusion. Which of the following interventions should the nurse implement to maintain asepsis?

54.A nurse receives a telephone prescription from the provider who states, “Four milligrams of morphine diluted with five milliliters of sterile water intravenous each morning at nine o’clock before a client’s dressing change”. Which of the following entries indicates that the nurse is transcribing the prescription correctly?

Morphine 4 mg IV bolus daily at 0900 before dressing changes, dilute medication with 5 mL of sterile water

A nurse is evaluating preoperative teaching to a female client who is to undergo surgery with general anesthesia. Which of the following statements by the client should indicate to the nurse that the teaching has been effective?

55.A nurse in an acute care setting is planning care for a client and is preparing to delegate tasks to an assistive personnel (AP). Which of the following tasks should the nurse delegate to the AP?

56.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?

57.A nurse is assessing a client who is postoperative following a cholecystectomy. Which of the following techniques should the nurse use to assess for peristalsis of the abdomen?

58.A nurse is preparing to administer ophthalmic drops to a client. Which of the following actions should the nurse take?

59.A nurse is planning care for a group of clients. Which of the following clients should the nurse late to first? RN VATI Fundamentals Assessment Paper