COMPLETED VATI Greenlight STUDY SET
A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? Correct Answer: The infusion pump ...
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COMPLETED VATI Greenlight STUDY SET
A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings
at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate
intervention by the nurse? Correct Answer: The infusion pump for administering contimuous feeding is
turned off.
A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings
should the nurse expect? Correct Answer: Hypotension
A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the
following foods should the nurse recommend? Correct Answer: Egg whites
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should
the nurse plan to take? Correct Answer: Use a designated stethoscope when caring for the toddler.
A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following
findings requires intervention by the nurse? Correct Answer: 1 cm of water present in the water seal
A nurse is reviewing the medical history of a client who is taking garlic supplement. The nurse should
identify that which of the following findings is a contraindication for taking this supplement? Correct
Answer: The client takes aspirin daily.
A nurse is planning to provide community education about viral hepatitis. Which of the following should
the nurse plan to include in the teaching? Correct Answer: series of four hepatitis vaccines is
recommended to prevent viral hepatitis.
A nurse is reviewing the history and physical of a client who has right ventricular heart failure. Which of
the following is an expected finding? Correct Answer: Elevated pulmonary artery pressure
A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The
client has two school-age children and a limited support system. Which of the following is the priority
nursing action? Correct Answer: Inform the client of available community resources.
A nurse is providing postoperative teaching to a client who has a newly-inserted pacemaker. Which of
the following statements by the client indicates that the teaching has been effective? Correct Answer: "I
will use my cell phone on the ear opposite of my pacemaker."
A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the
following findings indicates the client is experiencing an adverse effect of the medication? Correct
Answer: Decreased reflexes
A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should
the nurse take while caring for this client? Correct Answer: Wear an N95 respirator.
,A nurse manager is presenting information to the nursing staff regarding the appropriate use of client
restraints. Which of the following should the nurse include? (Select all that apply.) Correct Answer: The
nurse should pad the bony prominences. The nurse should remove the restraints every 2 hr. The
provider's prescription should include the
A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis.
Which of the following should the nurse include? Correct Answer: Educating the client how to cover
nose and mouth with tissues when coughing
A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions
should the nurse take? Correct Answer: Schedule routine care tasks during hours when the client is
awake.
A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of
the following actions should the nurse take? Correct Answer: Review deep breathing and coughing
exercises.
A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an
appropriate action for the nurse to take? Correct Answer: Report to the nurse manager.
A nurse in the recovery room is assessing a client who has a new chest tube. The nurse finds that the
water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the
following? Correct Answer: The tubing may be kinked.
A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When
admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of
the following tasks is most appropriate for the nurse to delegate to the LPN? Correct Answer: Measure
the amount of gastric drainage every 2 hr.
A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's
BMI falls within which of the following categories? Correct Answer: Healthy weight
A nurse is assessing a client who has a long arm cast. For which of the following findings should the
nurse monitor when assessing for acute compartment syndrome? Correct Answer: Change in mental
status
A nurse is planning care for a newly admitted client. Which of the following interventions should the
nurse plan to take first? (Click on the "Exhibit" button for additional information about the client. There
are three tabs that contain separate categories of data.) Correct Answer: Administer pain medication to
the client.
A community health nurse is performing a vision screening on a 4-month-old infant. When shining a light
source into the infant's visual field, which of the following is an expected finding? Correct Answer: The
infant closes their eyes.
A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at
home. Which of the following instructions should the nurse plan to include? Correct Answer: Place the
infusion pump cord against the baseboards.
, A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the
following actions by the assistive personnel requires the nurse to intervene? Correct Answer: Offers oral
fluids to the client
A nurse is assessing an infant who has water intoxication. Which of the following findings should the
nurse expect? Correct Answer: Generalized edema
A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is
reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse
expect? Correct Answer: Head compression
nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the
nurse implement droplet precautions? Correct Answer: Pertussis
A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which
of the following potential contraindications? Correct Answer: Shellfish allergy
A nurse at the family planning clinic triages several clients over the phone. Which of the following clients
should the nurse instruct to come to the clinic? Correct Answer: A client who has started taking oral
contraceptives and is experiencing bright red vaginal breakthrough bleeding
A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse
should incorporate which of the following communication methods? Correct Answer: Rephrase
sentences the client does not understand.
A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions
should the nurse take when conducting the interview? Correct Answer: Lean in slightly when speaking
to the client.
A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an
assistive personnel? Correct Answer: A client who had a stroke 2 days ago and needs help toileting
A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted
infections in the community. The purpose of which of the following is to generate new ideas to address
the public health concern? Correct Answer: A brainstorming session with nurses
A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding
her newborn. Which of the following instructions should the nurse include? Correct Answer: "Try to
have your baby empty your breasts with each feeding."
A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify the sequence of
actions the nurse should take. (Move the steps into the box on the right, placing them in the order of
performance. Use all the steps.) Correct Answer: Apply sterile gloves and place cleansing balls in
antiseptic solution. Attach prefilled syringe to indwelling catheter inflation hub. Cleanse the meatus with
the dominant hand in a downward motion. Lubricate the catheter and place fenestrated drape over
perineum. Insert the catheter until a flow of urine begins.
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