RN VATI Comprehensive Predictor Form B Exam, Questions
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1. A nurse is caring for a 5-year-old child
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Physical Examination: m
1510:
Upon visual inspection, throat is inflamed, tonsils appear pink,
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reddened andepiglottis is edematous and cherry red in appearance.
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Skin appears pale.
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Stridor noted upon inspiration with diminished bilateral lung sounds
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Nurse's Notes: m
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Child accompanied to emergency department by caregiver.
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,Caregiver stateschild has a sore throat and reports the child has
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m "pain on swallowing" and denies cough. Child is agitated and lean
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…Ans>> Condition: Epiglottis m m
Actions: Initiate droplet precautions and request a prescription for IV antibiotics
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Monitors: Breath sounds and temperature
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The nurse should anticipate initiating droplet precautions and requesting a
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prescription for IV antibiotics. The child is most likely experiencing epiglottis
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because of the clinical manifestations of a high fever, inflammation and
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redness of the throat, pale skin, stridor with inspiration, painful swallowing, no
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cough, is sitting in tripod position, and drooling. The nurse should monitor the
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child's temperature and breath sounds.
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2. A nurse is caring for a client who is on the spinal cord injury (SCI)
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unit
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Nurses'
NotesDay 3,
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m
Client admitted to SCI unit 3 days ago following C7 injury. Skin is
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m cool, pale, and dry to touch. Respirations easy and unlabored. Lung
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m sounds diminishedin lower lobes. Abdomen soft and nondistended
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m with active bowel sounds.
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,Client passed a small amount of hard formed stool this AM. Indwelling
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urinarycatheter draining clear yellow urine. Deep tendon reflexes (DTR
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are biceps 1+,triceps 1+, pa
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…Ans>> The client is most likely experiencing manifestations of pneumonia
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and autonomic dysreflexia.
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The nurse should analyze cues from the client's manifestations and determine
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thatthe client is most likely experiencing manifestations of pneumonia and
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autonomic dysreflexia. A client who has a cervical SCI is at risk for
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respiratory complications because spinal innervation to the respiratory
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muscles is disrupted. Adventitious breath sounds in the lower lobes bilaterally
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and a decrease in oxygen saturation
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to less than 92% can indicate pneumonia. The client's sudden increase in bloo
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, pressure, bradycardia, flushing of the skin above the area of the injury,
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m headache,and blurred vision are manifestations of autonomic dysreflexia,
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m which can be a life-threatening condition.
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3. A nurse is caring for a client who has abdominal pain
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Nurses'
m Notes0900 m
Client reports loss of appetite, weight loss, and fatigue for 1 week.
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m Reports abdominal pain, 6 on a scale from 0 to 10, for 2 days. Client
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m is a perioperativenurse, returned 1 week ago from a 2-week mission
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m trip to an underdevelopedcountry
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1200
Results of antibody studies obtained. Provider prescription for
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m antiviral med-ication pending. m m m
Physical
m Examination0930 m
Lung sounds clear bilaterally. Skin warm to touch and jau
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…Ans>> Hepatitis A: Client's risk from fecal-oral transmission, laboratory
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m results, and physical examination find-ings
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