Exam (elaborations)
MEDSURG VATI ASSESSMENT 90 Q'S and answers correct and verified 100%
MEDSURG VATI ASSESSMENT 90 Q'S and answers correct and verified 100%MEDSURG VATI ASSESSMENT 90 Q'S and answers correct and verified 100%
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...
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MEDSURG VATI ASSESSMENT 90 Q'S an uf uf uf uf uf
d answers correct and verified 100%
uf uf uf uf uf
Aufnurseufisufassistingufwithuftheufcareufofuffourufclients.ufWhichufofuftheuffollowingufclientsufisuftheufpriorityuffor
theufnurseuftoufsee
-AufclientufwhoufhasufchestuftubesufandufanufoxygenufSatufofuf90%
-ufaclientufwhoufhasufperipheralufedemaufandufurinaryufoutputufofuf130ufoveruf4hrs
-ufAufclientufwhoufhasufaufpermanentufpacemakerufwithufheartufrateufofuf76/min
-aufclientufwhoufhasufpericarditisufanduftemp.uf38ufcuf100.4uf-ufcorrectufanswers--
ufAufclientufwhoufhasufchestuftubesufandufanufoxygenufSatufofuf90%
Usinguftheufairway,ufbreathing,ufandufcirculationufapproachuftoufclientufcare,uftheufnurseufshouldufdetermineuftha
tuftheufpriorityuffindingufisuftheufclient'sufoxygenufsaturationuflevel,ufwhichufisufbelowuftheufexpectedufreferenceufr
angeufofuf95%uftouf100%.ufTherefore,uftheufnurseufshouldufattenduftoufthisufclientuffirst.
AufnurseufisufcollectingufdatauffromufaufclientufwhoufwasufadmittedufwithufaufGlasgowufComaufScaleufofuf3.ufWhich
ofuftheuffollowinguffindingsufshoulduftheufnurseufexpect?
-ufVacalizesufsound
-Blinksufeyesufwhenufasked
-Followsufmotorufcommands
-NonresponsiveufCommandsuf-ufcorrectufanswers-NonresponsiveufCommands
AufclientufwhoufhasufaufGCSufofuflessufthanuf8ufhasufevidenceufofufsevereufheadufinjuryufandufisufinufaufcomatoseufstat
e.ufTheufGCSufisufaufstandardizeduftoolufthatufallowsufforuftheufevaluationufofufaufclient'suflevelufofufconsciousness.uf
Theuftestufisufdividedufintoufthreeufsectionsufthatufevaluateufeyeufopening,ufmotorufresponse,ufandufverbalufrespo
nse.ufTheufGCSufrangesuffromufaufhighufscoreufofuf15uf(fullyufalert)uftoufauflowufscoreufofuf3uf(fullyufcomatose).
Aufnurseufisufmonitoringufaufclientufwhoufhasufaufpneumothoraxufandufaufchestuftubeufinufplaceufwithufaufclosedufch
estufdrainageufsystemufconnecteduftouflowufsuction.ufForufwhichufofuftheuffollowinguffindingsufshoulduftheufnurseu
fnotifyuftheufchargeufnurse
,-ufFluctationufofuftheufwateruflevelufinuftheufwaterufsealufchamber
-constantufbublingufinuftheufsuctionufcontrolufchamber
-ufperiodicufbubblingufinuftheufwaterufsealufchamber
-ufPersistentufbubblingufinuftheufwaterufsealufchamberuf-ufcorrectufanswers--
ufPersistentufbubblingufinuftheufwaterufsealufchamber
Excessiveufandufpersistentufbubblingufinuftheufwater-
sealufchamberufindicatesufanufairufleakufinuftheufdrainageufsystem.ufTheufnurseufshouldufnotifyuftheufchargeufnurse
ufofufthisuffinding.
Aufnurseufisufreinforcingufteachingufwithufaufmaleufclientufwhoufhasufrightufsidedufhemiparesisufabout
preformingufADL's.ufWhichufofuftheuffollowingufinstructionsufshoulduftheufnurseufincludeufinuftheufteaching
-Combufyourufhairufwithuftheufunaffectedufarm
-Dressufyourufunaffectedufsideuffirst
chooseufclothingufwithufbuttons
-shaveufwithufyourufaffectedufsideuf-ufcorrectufanswers-Combufyourufhairufwithuftheufunaffectedufarm
Theufnurseufshouldufinstructuftheufclientuftoufbrushuftheirufhairufwithuftheufunaffectedufarmuftoufreduceuffrustratio
nufandufincreaseufindependenceufandufself-esteem.
Aufnurseufisufcollectingufdatauffromufaufclientufandufauscultatesufintermittentufhigh-
pitchedufsoundsufduringufinspirationufoveruftheuflowerufbaseufofuftheuflungs.ufTheufnurseufshouldufidentifyufthisuffi
ndingufasufwhichufofuftheuffollowinguflungsufsounds
-ufFineufcrackles
-stridor
-rhonchi
-frictionuf-ufcorrectufanswers--ufFineufcrackles
Fineufcracklesufareufauscultatedufinuftheufbaseufofuftheuflungsufasufairufmovesufthroughufairwayufsecretions.ufFineuf
cracklesufareufintermittent,ufhigh-pitchedufsoundsufheardufmoreufoftenufduringufinspiration.
Aufnurseufisufcollectingufdatauffromufaufclientufwhoufhasufcoronaryufarteryufdisease.ufWhichufofuftheuffollowing
manifestationsufshoulduftheufnurseufidentifyufasufanufindicationufthatuftheufclientufhasufanginauf(ufSatA)
, -ufChestufDiscomfortufRadiated
-ufPainuflastinguflessufthatuf15mins
-ufPainufthatufisufrelievedufwithufrestuf-ufcorrectufanswers--ufChestufDiscomfortufRadiated
-ufPainuflastinguflessufthatuf15mins
-ufPainufthatufisufrelievedufwithufres
Aufnurseufisufreceivingufchange-of-shiftufreportufforufaufgroupufofufclients.ufWhichufofuftheuffollowingufclients
shoulduftheufnurseufplanuftoufseeuffirst?
-ufAufclientufwhoufhasufdiabetesufmellitusufwithufdiaphoreticuf-ufcorrectufanswers-
Aufclientufwhoufhasufdiabetesufmellitusufwithufdiaphoretic
Whenufusinguftheufurgentufvs.ufnonurgentufapproachuftoufclientufcare,uftheufnurseufshouldufdetermineufthatuftheuf
priorityufactionufisuftoufattenduftoufaufclientufwhoufhasufdiabetesufmellitusufandufisufdiaphoretic.ufDiaphoresisufisufa
ufmanifestationufofufhypoglycemiaufandufcanufleaduftoufdecreasedufcerebraluffunction.ufTheufnurseufshouldufchec
kuftheufclient'sufbloodufglucoseufandufadministerufauffast-actingufglucoseufasufprescribed.
Aufnurseufisufcollectingufdatauffromufaufclientufwhoufhasuftuberculosisufandufstartedufcombinationuftherapy
2monthsufago.ufWhichufofuftheuffollowingufdiagnosticufresultsufindicatesufthatuftheufclientufisufadheringuftoufthe
medicationufregimen.
-ufAufnegativeufchestufX-ray
-ufAufnegativeufsputumufculture
-Aufnegativeuftuberculinufskinuftest
-Aufnegativeuftiterufforufcytomegalovirusuf-ufcorrectufanswers-Aufnegativeufsputumufculture
Tuberculosisufisufanufinfectiousufdiseaseufspreadufthroughufairborneufdroplets.ufSputumufculturesufareufobtaine
duftoufbothufdiagnoseuftuberculosisufanduftoufdetermineufwhetheruftheufmedicationuftreatmentufhasufbeenufeffe
ctive.ufAfteruftheufclientufbeginsufantibioticuftreatmentufforuftuberculosis,ufaufsputumufcultureufisufobtainedufmon
thly.ufAufnegativeufcultureufisufanufindicationufthatuftheufclientufisufnouflongerufinfectiousufanduftheufmedicationufth
erapyufhasufbeenufeffective.
Aufnurseufisufcollectingufdatauffromufaufclientufwhoufhasufbacterialufmeningitis.ufWhichufofuftheuffollowing
findingsufshoulduftheufnurseufexpect?
-ufSevereufHeadacheuf-ufcorrectufanswers--ufSevereufHeadache