RN VATI Fundamentals 2019 Assessment

how to assess for clonus?

Use a reflex hammer.MY ANSWER The nurse should use a reflex hammer to assess the client for clonus. The reflex hammer causes the muscle to immediately contract due to a two-neuron reflex arc involving the spinal or brainstem segment that innervates the muscle. Administer magnesium sulfate.Administering magnesium sulfate is not a test for clonus. Magnesium sulfate is administered for convulsions, hypomagnesemia, and hypertension. Perform a Romberg test.A Romberg test assesses balance, gross-motor function, and equilibrium. Test the gait for symmetry.Testing the client's gait gives the nurse information about symmetry, walking ability, posture, and balance.

A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the nurse take to maintain the client's skin integrity?

Use an alcohol-free barrier product

A nurse is evaluating preoperative teaching with a client who is to undergo surgery with general anesthesia. Which of the following statements by the client indicates an understanding of the teaching?

"I should remove nail polish form my fingers before surgery."

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"

...using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

"I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them."

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."

A school RN is teaching a group of parents about measures to prevent firearm injuries in the home. Which of the following instructions should the nurse include in the teaching?

"Keep ammunition and guns in seperate, locked locations."

A home health nurse is making an initial assessment visit to an older client who has type 1 diabetes mellitus. Which of the following statements should the nurse make to evaluate the clients ability ot measure blood glucose accurately?

"Please use your glucometer and show me the results."

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 home health RN is teaching a client who has a latex allergy about items typically found in the home that can trigger an allergic reaction. Which of the following items should the RN instruct the client to avoid? (Select all that apply)

-Dishwashing gloves -Adhesive tape -Bananas -Rubber bands

A RN is completing a preadmission interview for a client who is ti undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the RN include when planning care for the client's surgery?

-Notify ancillary dept. of the client's allergy -Label the surgical suite as latex-free -Ensure a latex allergy care is available

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.

A nurse has administered 5 mL of medication to a client via NG tube. Then used 30 mL of water to flush the tue both before and after the instillation. the nurse should document which of the following amounts as liquid intake for the client?

65 mL

RN in a rehab unit is assessing a group of clients who have a TBI. The RN should identify that which of the following clients requires a priority referral?

A client who consistently coughs after drinking liquids

A nurse in a long-term care facility is planning to use therapeutic tough for a group of selected clients who have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for which of the following patients?

A client who has chronic back pain and a history of physical maltreatment

A nurse is preparing to delegate task for multiple clients at the beginning of the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Assist a client with ambulation

A nurse is providing teaching to a client who has a new dx of type 1 DM. The client expresses feelings of hopelessness about managing the disease. Which of the following actions should the RN take first?

Explore the client's past coping mechanisms

A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?

Fear of medical test results

A nurse is performing postmortem care for an older client who had just died. Which of the following actions should the nurse take?

Identify the client using two identifiers

A RN is reviewing data in a client's medical record. Which of the following info should the RN expect to find in the discharge summary section?

List of community resources

A RN manager is teaching a group of newly licensed RN's about procedures are within their scope of practice. Which if the following examples should the RN include in the teaching?

Monitoring a continuous intra-arterial infusion of a thrombolytic medication

A nurse receives a telephone prescription form the provider, who states, "four milligrams of morphine diluted with 5 milliliters of sterile water intravenous each morning at nine o'clock before client dressing changes." Which of the following entries by the nurse indicates correct transcription of the prescription?

Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute medication with 5 mL of sterile water

A RN is reviewing the medical record of a client is postoperative. Based on the info in the medical record, which of the following actions should the RN take first?

Obtain a RX for IV fluids

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.

A RN is caring for a client who has terminal illness. The client request a DNR order, but their family opposes the decision. Which of the following actions should the nurse take first.

Gather information to support the client's request for a DNR order

A RN is assessing an older adult client who has become increasingly confused and agitated in the last 48 hrs. Which of the following conditions should the nurse expect?

UTI

A RN is applying a new transdermal patch to a client. Which of the following actions should the RN take?

Wear gloves when applying the patch

A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia pad. Which of the following actions should the nurse take?

Cover the pad with a pillowcase before application. over the pad with a pillowcase before application.MY ANSWERThe nurse should cover the aquathermia pad with a thin towel or pillowcase before use because applying the pad directly to the skin could cause a burn injury. Apply the pad for 45 min per application.An application of the aquathermia pad usually lasts 30 min. Prolonged application of the pad places the client at risk for a burn injury. Set the temperature of the aquathermia pad to 50° C (122° F).The nurse should set the temperature of the aquathermia pad to 40° C (104° F). Use safety pins to hold the pad in place.The nurse should not use pins to hold the aquathermia pad in place because they can cause a leak. The nurse should use tape or gauze ties to hold the pad in place.

A nurse is creating a plan of care for a client who requires suture removal. Which of the following actions should the nurse plan to take?

Cut the sutures as close to the skin as possible. Pull the visible part of the suture through the underlying tissue.The nurse should identify that pulling the visible part of the suture through underlying tissue increases the client's risk for infection. Cleanse the wound with sterile water prior to removing the sutures.The nurse should cleanse the wound with an antimicrobial solution prior to removing the sutures. This decreases the client's risk of infection. Cut the sutures as close to the skin as possible.MY ANSWERThe nurse should cut the sutures as close to the skin as possible. The exposed part of the suture contains bacteria, so cutting close to the skin prevents bacteria from entering the clean wound, decreasing the risk for infection. Remove the sutures in a consecutive order.The nurse should remove every other suture in an alternating pattern. Removing the sutures in a consecutive order is not recommended because this could increase the risk for wound dehiscence.

RN is preparing to assess a client's cardiac function by auscultating heart sounds at the cardiac landmarks. Which of the following areas should the RN identify as the pulmonic area? (hotspot question)

D (right sternal border, second intercostal space) A is incorrect. The nurse should identify that this area is the mitral area of the cardiac landmarks, which is considered the point of maximal impulse. This is also the area in which the apical heart rate is best auscultated. This area is located at the fifth intercostal space, to the left of the sternum, at the left midclavicular line.B is incorrect. The nurse should identify that this area is the tricuspid area of the cardiac landmarks, which is located at the left fourth or fifth intercostal space, near the sternum.C is correct. The nurse should identify that this is the pulmonic area of the cardiac landmarks, which is located at the left second intercostal space, near the sternum.D is incorrect. The nurse should identify that this is the aortic area of the cardiac landmarks, which is located at the right second intercostal space, near the sternum.

A RN is assessing a client who has hypokalemia. Which of the following findings should the NR expect?

Decreased bowel sounds Strong, bounding pulseA weak, irregular pulse is an expected finding of hypokalemia. Positive Chvostek's signA positive Chvostek's sign is an indication of hypocalcemia or hypomagnesemia. Chvostek's sign occurs when the nurse taps the client's facial nerve, resulting in contraction of the facial muscle. Hyperactive reflexesHypoactive, or diminished, reflexes are an expected finding of hypokalemia or hypocalcemia. Decreased bowel soundsMY ANSWERDecreased bowel sounds are an indication of hypokalemia because of decreased excitability of cells, resulting in less responsiveness to normal stimuli in nerves and muscles.

A nurse is performing a family assessment for a client who has recently developed paraplegia following a stroke. Which of the following actions should the nurse take first?

Determine how the client views the concept of family

A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following actions should the nurse take first?

Determine the source of the client's stress

rinne test?

Place a vibrating tuning fork on the top of the client's head.The nurse should place a vibrating tuning fork on the top of the client's head when performing the Weber's test. The Rinne test assesses the transmission of sound through bone conduction. Move a vibrating tuning fork's prongs in front of the client's left or right ear canal.The nurse should perform the Rinne test by placing the handle of a vibrating tuning fork on the client's mastoid process and then moving the vibrating prongs 1 to 2 cm (0.4 to 0.8 in) in front of the client's left or right ear canal. The Rinne test compares bone conduction with air conduction. The client is expected to hear sound conduction by air for twice as long as bone conduction. Activate a tuning fork and place the prongs on the client's occipital area.MY ANSWERWhen performing the Rinne test, the nurse should activate the tuning fork and place the handle on the mastoid process near one ear until the client no longer hears the sound created by the vibration. Instruct the client to occlude one ear and repeat a softly spoken phrase by the nurse.The nurse should perform the whisper test by whispering a phrase and then have the client repeat the phrase to assess for high-frequency hearing.

A home health nurse is teaching about oral care to the family of a client who is in a coma. Which of the following task should the nurse instruct the family to perform first?

Place the client in a side-lying position

thoracentesis post procedure?

Position the client on the unaffected side.The nurse should position the client on the unaffected side to help facilitate expansion of the affected lung. Maintain the head of the bed at 45°.MY ANSWERSome facility protocols recommend that the nurse should raise the head of the bed to 30° for at least 30 min to facilitate expansion of the affected lung and ease of breathing. Measure the client's abdominal girth at the level of the umbilicus.The nurse should measure the client's abdominal girth following an abdominal paracentesis, rather than a thoracentesis. Leave the puncture site open to air.The nurse should apply a small, sterile dressing over the puncture site.

RN is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which actions should the RN take next?

Position the client on their side. Prepare to initiate antibiotic therapy.The nurse should prepare to initiate antibiotic therapy because stomach contents in the respiratory tract will likely lead to pneumonia. However, there is another action the nurse should take first. Obtain a prescription for a chest x-ray.The nurse should obtain a prescription for a chest x-ray to determine if the client aspirated stomach contents into the respiratory tract. However, there is another action the nurse should take first. Position the client on their side.MY ANSWERThe greatest risk to this client is aspiration from possible dislodgment of the NG tube and aspirated stomach contents into the respiratory tract. Therefore, the priority nursing action to decrease exacerbation of the condition is to position the client on their side. Suction the client's orotracheal airway.The nurse should suction the client's orotracheal airway to prevent further aspiration of stomach contents into the respiratory tract. However, there is another action the nurse should take first.

A nurse is moving a client up in bed with assistance of another nurse. Which of the following actions should the nurse take?

Positions the client's arms across their chest.

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

A charge RN is providing an in-service about client advocacy to a group of newly licensed RN. Which of the following examples should the RN include?

Providing information about advance directives to a client

A nurse is preparing to administer drops to a client. Which of the following actions should the nurse take?

Rest the non-dominant hand on the clients forehead while instilling the drops. Tilt the client's head away from the side receiving the drops.The nurse should help the client assume a comfortable position, either sitting or lying, with their head tilted backward and looking up at the ceiling. Instill the drops directly onto the cornea of the eye receiving the drops.The nurse should never instill an eye medication directly onto the cornea due to the high risk for injury. Instead, the nurse should expose the lower conjunctival sac by drawing down the skin over the client's cheekbone. The nurse should then instill the prescribed number of drops onto the lower conjunctival sac. Rest the dominant hand on the client's forehead while instilling the drops.The nurse should rest the dominant hand on the client's forehead while instilling the drops. This action stabilizes the nurse's hand and ensures that the hand will move with the client if they move suddenly. This simple precaution reduces the risk of striking the client's eye with the dropper and injuring it. Hold the medication dropper 0.5 cm (0.2 in) above the conjunctival sac.MY ANSWERThe nurse should hold the medication dropper 1 to 2 cm (0.4 to 0.8 in) above the conjunctival sac. With this distance, the client is less likely to blink. Therefore, the eye drop is instilled more efficiently. It is also important to not touch the conjunctival sac or cornea.

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