MEDSURG VATI ASSESSMENT 90 Q'S
21) A nurse is caring for a client who has type 1 diabetes mellitus and reports hunger and
weakness. The clients blood glucose is 50gm/dL. Which of the following actions should the
nurse take
-Have the client drink a glass of milk - ANS--Have the client drink a glass of milk
A nurse examining a client's rhythm strips notices no visible P waves but many small, erratic
spikes throughout the strip as well as variable ventricular rate. The nurse should identify and
report this pattern as which of the following dysrhythmias?
- Atrial Fibrillation - ANS-- Atrial Fibrillation
The nurse should identify that during atrial fibrillation, the atrioventricular node cannot respond
to so many atrial impulses. Therefore, it sends impulses to the ventricles in an erratic way, which
accounts for these characteristics on the client's rhythm strip.
A nurse in a long term facility is delegating client care tasks to staff members. Which of the
following tasks should the nurse assign to an assistive personnel (AP)?
- Document a client's output for the shift - ANS-- Document a client's output for the shift
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
- Slow the rate of fluid flow - ANS-- 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 height of the enema bag will
decrease the rate the fluid enters the bowel. Tap water enemas consist of 500 mL to 1 L of fluid
that is instilled into the bowel to soften feces. The volume of fluid stimulates peristalsis.
A nurse is assisting a client to move from a bed to a wheelchair. The client had a total knee
arthroplasty 2 days ago and reports generalized weakness. Which of the following is an
appropriate action by the nurse
-Place the wheelchair at 90 angle to the bed
- Lock the wheels of the bed and the wheelchair
- ask the client to place the foot of the eaker leg beneath the edge og the bed
_ Elevate the bed to position of comfort for the nurse - ANS-- Lock the wheels of the bed and
the wheelchair
The nurse should always keep the wheels of the bed and wheelchair in the locked position to
prevent them from moving when transferring a client.
,A nurse is assisting a client who has hypertension in making healthy dietary selections
regarding
sodium intake. Which of the following foods should the nurse instruct the client to avoid?
- Pretzels - ANS-- Pretzels
A nurse is assisting a client who is on bed rest to preform isometric exercises. Which of the
following actions should the nurse take
- Instruct the client to tighten and then relax muscles repeatedly - ANS-- Instruct the client to
tighten and then relax muscles repeatedly
The nurse should instruct the client to perform isometric exercises by holding muscles tight for 5
seconds and then relaxing them. This form of exercise involves static contraction of a muscle
without any movement of the joint. Immobility can cause systemic physiologic effects such as
increased heart rate, increased bone demineralization, decreased muscle strength, joint
contractures, and activity intolerance. Isometric exercises increase muscle mass, tone, and
strength while promoting circulation.
A nurse is assisting with the care of a client who has cellulitis and is receiving IV
Ceftriaxone.During data collection, the nurse notes the client is flushed and the client reports
urticarial. After stopping the IV infusion, which of the following actions should the nurse take
first?
-Check clients respiration - ANS-Check clients respiration
After stopping the IV infusion, the first action the nurse should take when using the airway,
breathing, circulation approach to client care is to count the client's respirations and monitor for
dyspnea because a client experiencing an allergic reaction can progress to anaphylactic shock
and death.
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 an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 130 over 4hrs
- A client who has a permanent pacemaker with heart rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4 - ANS-- A client who has chest tubes and an
oxygen Sat 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 caring for a client who has heart failure and a new prescription for furosemide. The
nurse should monitor the client for which of the following manifestations as an adverse effect of
the medication.
, - Tinnitus - ANS-- Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing loss. Audiometry
is recommended for clients receiving prolonged IV furosemide.
A nurse is caring for a client who has Phantom pain after healing from a below knee amputation.
which of the followingmedication should the nurse expect the provider to prescribe to relieve the
clients pain?
- Pregablin - ANS-Pregabalin
Pregabalin is an anticonvulsive medication that is an adjuvant medication for treating
neuropathic pain such as phantom limb pain. Typically, with this type of pain, analgesics and
opioids are ineffective.
A nurse is caring for a client who has type1 diabetes mellitus and has undergone a below the
knee amputation. Which of the following is the highest priority findings
- Skin flap of the residual limb is cool to the touch - ANS-- 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 caring for a client who is preoperative and does not speak the same language as the
nurse. Which of the following actions should the nurse take
- Incorporate the use of the pictures as a tool of communication - ANS-- Incorporate the use of
the pictures as a tool of communication
The nurse should use communication tools, such as a message board, cards, or pictures, to
assist the client in communicating her needs.
A nurse is caring for a client who is receiving peripheral IV therapy. The nurse notes that the IV
site is red, warm, and painful to the touch. Which of the following actions should the nurse take?
- Discontinue the IV and apply a warm, moist compress to the site - ANS-- Discontinue the IV
and apply a warm, moist compress to the site
Complications of intravenous therapy involve inflammation of the vein, phlebitis, and can include
the presence of clots or thrombophlebitis. Manifestations of these complications include pain at
the IV site, along with redness and warmth. The nurse should stop the infusion, remove the IV,
inspect the catheter to ensure it is intact, and apply a warm, moist compress to the area.
A nurse is caring for a client who is scheduled for a right total hip arthroplasty. Which of the
following actions should the nurse take prior to the procedure? SATA
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