RN VATI Fundamentals Assessment
A nurse is preparing to mix short-acting and intermediate-acting insulin in one syringe to administer to a client who has type 1 diabetes mellitus. Identify the sequence the nurse should follow.
1: Draw up the volume of insulin from the intermediate-acting insu...
RN V ATI Fundamentals
Assessment
A nurse is preparing to mix short-acting and intermediate-acting insulin in one syringe to administer to a client who has type 1 diabetes mellitus. Identify the sequence the nurse should follow.
1: Draw up the volume of insulin from the intermediate-acting insulin vial. 2: Inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting insulin vial.
3: Inject the volume of air equal to the insulin dose form the short-acting insulin vial
4: Withdraw the prescribed amount of insulin form the short-acting insulin vial.
5: Withdraw the prescribed amount of insulin form the intermediate-acting insulin vial.
To mix insulin from two vials in the same syringe, the nurse should first draw up a volume of air equal to the volume of insulin from the intermediate-acting insulin vial. The nurse should then inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting insulin vial, making sure the needle does not touch the insulin. Next, the nurse should inject the volume of air equal to the insulin dose from the short-acting insulin vial. Then, the nurse should withdraw
the prescribed amount of insulin from the short-acting insulin vial. Lastly, the nurse should withdraw the prescribed amount of insulin from the intermediate-
acting insulin vial. The insulins are now mixed and ready to administer.
A nurse is assessing a client who wears partial dentures and reports mouth pain.
Which of the following actions should the nurse take? Advise the client to rinse their mouth and dentures after each meal.
The nurse should advise the client to rinse their mouth and dentures after each meal to remove food and particles and to promote healing of gums and oral mucosa.
The nurse should instruct the client to rinse their mouth four times each day with mild rinses, such as normal saline or sodium bicarbonate solution. The nurse should inform the client that mouthwashes containing alcohol dry the oral mucosa and can irritate tissue.
The nurse should instruct the client to brush their remaining teeth with a soft toothbrush at least twice each day to reduce the risk for gum abrasions.
The nurse should avoid using lemon-glycerin sponges because they can cause erosion of the client's tooth enamel, dry the mucous membranes, and increase the client's current discomfort.
A nurse is planning care for a client who has dysphagia and is at risk for aspiration. Which of the following referrals should the nurse make?
Speech-language pathologist
The nurse should recommend a referral for a client who has dysphagia to a speech-language pathologist. Clients who have dysphagia have difficulty swallowing and are at risk for aspiration. The speech-language pathologist can perform a swallow study to determine the extent of the client's dysphagia and work with the client to develop new swallowing techniques.
A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse take prior to performing the teaching? (select all that apply)
- Establish the client's learning needs
- Determine the client's literacy level
- Evaluate the client's readiness for learning
- Identify the client's learning style A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the SBAR communication tool?
Previous treatments
The nurse should include previous treatments in the "background" portion of the SBAR communication tool. Other information the nurse should include in the "background" portion is the client's admission history, diagnosis, pertinent medical history, and code status. The nurse should include physical findings in the
"assessment" portion of the SBAR communication tool. The nurse should include questions regarding client care in the "recommendation" portion of the SBAR communication tool. The nurse should include the client's present condition in the "situation" portion of the SBAR communication tool.
A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy utilizing a compressed oxygen system . Which of the following statements by the client indicates an understanding of the teaching?
"I will store oxygen tanks in an upright position"
This statement by the client indicates an understanding of the teaching. The nurse
should instruct the client to store oxygen tanks in an upright position in a holder to prevent damage to the tank and injury to the client and the client's family. The nurse should instruct the client to check the oxygen equipment at least once daily
to determine if it is set to the prescribed oxygen rate. The nurse should instruct the client to place the oxygen equipment 2.4 m (8 ft) from a heat source to prevent injury from accidental combustion.
A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I am afraid of dying." Which of the following responses should the nurse make?
"It must me a very difficult time for you."
The nurse is using the therapeutic communication technique of verbalizing the implied. This technique puts into words what the client has said indirectly and creates a more positive nurse-client relationship.
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