VATI PN MEDSURG EXAM | ALL QUESTIONS AND
CORRECT ANSWERS WITH EXPLANATIONS |
ALREADY GRADED A+ | VERIFIED ANSWERS |
LATEST VERSION | JUST RELEASED
A nurse is contributing to the plan of care for a client who is in skeletal
traction. Which of the following interventions should the nurse include? -----
-CORRECT ANSWER---------------Keep the client's body centered in the
bed.
The nurse should keep the client's body centered on the bed to
maintain alignment of the body with the direction of the pull of
traction. This will ensure continued alignment of the bone.
A nurse is contributing to the plan of care for a client who has dysphagia
following a stroke. Which of the following actions should the nurse include
in the plan of care to prevent aspiration? ------CORRECT ANSWER-----------
----Keep the client upright for 30 min after a meal.
The nurse should keep the client upright for 30 to 60 min after a meal
to reduce the risk for aspiration.
A nurse is reinforcing postoperative teaching with a client who is scheduled
for cataract surgery on his right eye. Which of the following instructions
should the nurse include? ------CORRECT ANSWER---------------"Wear a
protective eye shield while sleeping
The nurse should remind the client to wear an eye shield while
sleeping. This protects the operative eye from injury due to rubbing or
pressure from the pillow.
,A nurse is collecting data from a client who was admitted with a Glasgow
coma scale (GCS) of 3. Which of the following findings should the nurse
expect? ------CORRECT ANSWER---------------Nonresponsive to 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).
A nurse is caring for a client who has type 1 diabetes mellitus and has
undergone a below-the-knee amputation. Which of the following is the
nighest priority finding? ------CORRECT ANSWER---------------Skin flap of
the residual limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding is that the skin flap of
the residual limb is cool to the touch. The nurse should immediately
report this finding to the provider. The skin flap of the residual limb
should be warm to the touch, indicating adequate tissue perfusion.
A nurse is reinforcing teaching about the prevention of sexually transmitted
infections (STIS) with a client who is sexually active. Which of the following
information should the nurse include in the teaching? ------CORRECT
ANSWER---------------Inserting a polyurethane female condom is effective
for prevention of STIS.
The nurse should reinforce that polyurethane female condoms are
effective in preventing STIS, including HIV.
A nurse is administering a tap water enema to a client who has
constipation. The client reports abdominal cramping during instillation of the
,enema. Which of the following actions should the nurse take? ------
CORRECT ANSWER---------------Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the
intestinal spasm to pass if cramping occurs during administration of
the enema. Lowering the helght of the enema bag will decrease the
rate the fluid enters the bowel. Tap water enemas consist of 500 ml to
1Lof fluid that is instilled into the bowel to soften feces. The volume
of fluid stimulates peristalsis.
A nurse is reinforcing teaching about mammograms with an adult client
who is postmenopausal. Which of the following statements indicates to the
nurse that the client understands the teaching? ------CORRECT ANSWER--
-------------I should have a mammogram every 1 to 2 years."
The nurse should remind the client that the American Cancer Society
recommends clients continue to have a mammogram every 1 to 2
years as they age and are in good health.
A nurse is collecting data from a client and auscultates intermittent high-
pitched sounds during inspiration over the lower base of the lungs. The
nurse should identify this finding as which of the following lung sounds? ----
--CORRECT ANSWER---------------Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves
through airway secretions. Fine crackles are intermittent, high-
pitched sounds heard more often during inspiration.
A nurse is assisting with the care of four clients. Which of the following
clients is the priority for the nurse to see? ------CORRECT ANSWER---------
------A client who has chest tubes and an oxygen saturation 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 preparing to perform a closed irrigation of an indwelling urinary
catheter for a client who had abdominal surgery. Which of the following
actions should the nurse plan to take? ------CORRECT ANSWER--------------
-Stop the irrigatian if resistance is felt during fiuid instillation.
The nurse should plan to discontinue the irrigation and contact the
provider if resistance is felt. This can indicate the client has a total
occlusion of the catheter or that the catheter is displaced.
A nurse is reviewing the medical record of a client who has systemic lupus
erythematosus (SLE). Which of the following findings should the nurse
expect? ------CORRECT ANSWER---------------Joint pain
The nurse should expect a client who has SLE to exhibit
manifestations such as joint pain, photosensitivity. hair loss, and
malaise. SLE is an autoimmune disease that causes the body to
produce antibodies that attack body cells instead of pathogens, such
as bacteria and fungl.
A nurse is preparing to transfer a client from a bed to a chair following a
total knee arthroplasty. The client has a prescription for partial weight
bearing. Which of the following actions should the nurse take? ------
CORRECT ANSWER---------------Position feet apart before pivoting the
client.
The nurse should spread their feet apart before pivoting the client to
maintain a wide base of support.
CORRECT ANSWERS WITH EXPLANATIONS |
ALREADY GRADED A+ | VERIFIED ANSWERS |
LATEST VERSION | JUST RELEASED
A nurse is contributing to the plan of care for a client who is in skeletal
traction. Which of the following interventions should the nurse include? -----
-CORRECT ANSWER---------------Keep the client's body centered in the
bed.
The nurse should keep the client's body centered on the bed to
maintain alignment of the body with the direction of the pull of
traction. This will ensure continued alignment of the bone.
A nurse is contributing to the plan of care for a client who has dysphagia
following a stroke. Which of the following actions should the nurse include
in the plan of care to prevent aspiration? ------CORRECT ANSWER-----------
----Keep the client upright for 30 min after a meal.
The nurse should keep the client upright for 30 to 60 min after a meal
to reduce the risk for aspiration.
A nurse is reinforcing postoperative teaching with a client who is scheduled
for cataract surgery on his right eye. Which of the following instructions
should the nurse include? ------CORRECT ANSWER---------------"Wear a
protective eye shield while sleeping
The nurse should remind the client to wear an eye shield while
sleeping. This protects the operative eye from injury due to rubbing or
pressure from the pillow.
,A nurse is collecting data from a client who was admitted with a Glasgow
coma scale (GCS) of 3. Which of the following findings should the nurse
expect? ------CORRECT ANSWER---------------Nonresponsive to 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).
A nurse is caring for a client who has type 1 diabetes mellitus and has
undergone a below-the-knee amputation. Which of the following is the
nighest priority finding? ------CORRECT ANSWER---------------Skin flap of
the residual limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the
nurse should determine that the priority finding is that the skin flap of
the residual limb is cool to the touch. The nurse should immediately
report this finding to the provider. The skin flap of the residual limb
should be warm to the touch, indicating adequate tissue perfusion.
A nurse is reinforcing teaching about the prevention of sexually transmitted
infections (STIS) with a client who is sexually active. Which of the following
information should the nurse include in the teaching? ------CORRECT
ANSWER---------------Inserting a polyurethane female condom is effective
for prevention of STIS.
The nurse should reinforce that polyurethane female condoms are
effective in preventing STIS, including HIV.
A nurse is administering a tap water enema to a client who has
constipation. The client reports abdominal cramping during instillation of the
,enema. Which of the following actions should the nurse take? ------
CORRECT ANSWER---------------Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the
intestinal spasm to pass if cramping occurs during administration of
the enema. Lowering the helght of the enema bag will decrease the
rate the fluid enters the bowel. Tap water enemas consist of 500 ml to
1Lof fluid that is instilled into the bowel to soften feces. The volume
of fluid stimulates peristalsis.
A nurse is reinforcing teaching about mammograms with an adult client
who is postmenopausal. Which of the following statements indicates to the
nurse that the client understands the teaching? ------CORRECT ANSWER--
-------------I should have a mammogram every 1 to 2 years."
The nurse should remind the client that the American Cancer Society
recommends clients continue to have a mammogram every 1 to 2
years as they age and are in good health.
A nurse is collecting data from a client and auscultates intermittent high-
pitched sounds during inspiration over the lower base of the lungs. The
nurse should identify this finding as which of the following lung sounds? ----
--CORRECT ANSWER---------------Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves
through airway secretions. Fine crackles are intermittent, high-
pitched sounds heard more often during inspiration.
A nurse is assisting with the care of four clients. Which of the following
clients is the priority for the nurse to see? ------CORRECT ANSWER---------
------A client who has chest tubes and an oxygen saturation 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 preparing to perform a closed irrigation of an indwelling urinary
catheter for a client who had abdominal surgery. Which of the following
actions should the nurse plan to take? ------CORRECT ANSWER--------------
-Stop the irrigatian if resistance is felt during fiuid instillation.
The nurse should plan to discontinue the irrigation and contact the
provider if resistance is felt. This can indicate the client has a total
occlusion of the catheter or that the catheter is displaced.
A nurse is reviewing the medical record of a client who has systemic lupus
erythematosus (SLE). Which of the following findings should the nurse
expect? ------CORRECT ANSWER---------------Joint pain
The nurse should expect a client who has SLE to exhibit
manifestations such as joint pain, photosensitivity. hair loss, and
malaise. SLE is an autoimmune disease that causes the body to
produce antibodies that attack body cells instead of pathogens, such
as bacteria and fungl.
A nurse is preparing to transfer a client from a bed to a chair following a
total knee arthroplasty. The client has a prescription for partial weight
bearing. Which of the following actions should the nurse take? ------
CORRECT ANSWER---------------Position feet apart before pivoting the
client.
The nurse should spread their feet apart before pivoting the client to
maintain a wide base of support.
