VATI: Fundamentals - Pre-Assessment Quiz

A nurse is calculating a client's I&O for an 8-hour shift. The client's intake included: - 1,000 mL 0.9% sodium chloride IV - one 6-oz cup of coffee - 6 oz of water - one 180-mL bowl of soup - 3 oz of flavored gelatin - 3 oz of ice cream How many mL should the nurse document as the client's total intake for the shift? (Round the answer to the nearest whole number. Use a leader zero if it applies. Do not use a trailing zero.)

1720 mL 1 oz = 30 mL

A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching? A. "It is a good idea to use the handrails in the bathroom." B. "I should use chairs without armrests." C. "I should place a throw rug over electrical cords." D. "I should get a longer cord for my telephone."

A. "It is a good idea to use the handrails in the bathroom." Handrails or grab bars in the bathroom can help prevent falls. Clients should use them for added stability when changing positions. B. Chairs without armrests increase the risk for falls to the side. Armrests provide stability as the client sits down or rises from the chair. C. Throw rugs increase the risk of trips and falls. Electrical cords should be out of the way of walking areas. D. Long telephone cords increase the risk for tripping and falling.

A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postoperative placement of prosthesis? A. "You will do special exercises in advance of getting your prosthesis." B. "You will be fitted for your prosthesis at the time of surgery." C. "A special pressure dressing will remain on to cushion your prosthesis." D. "The prosthesis will be adjustable depending on what shoe you are wearing."

A. "You will do special exercises in advance of getting your prosthesis." The physical therapist will teach muscle strengthening exercises to prepare the client for prosthesis use. B. Some clients are fitted at the time of surgery with a prosthesis, but it is temporary. Most clients are fitted for their prosthesis after the residual limb has healed. C. Special dressings or devices are used to shape and shrink the residual limb to fit the prosthesis but they do not remain on after the limb has healed. D. The client should bring a pair of shoes to the fitting so measurements can be made and the length adjusted to that heel height, but the prosthesis will then be permanently structured and not adjustable.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? A. Apply a moisture barrier ointment to the client's skin B. Clean the client's skin and perineum with hot water after each episode of incontinence C. Check the client's skin every 8 hr for signs of breakdown D. Request a prescription for the insertion of an indwelling urinary catheter

A. Apply a moisture barrier ointment to the client's skin Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine. B. The nurse should wash the client's skin with mild soap and warm water and pat it dry gently. Hot water can be irritating and can dry the skin. C. Clients who are incontinent are at a high risk for skin breakdown. Examining the skin at least every 2 hr and providing hygiene are two initial defenses against skin breakdown. D. Although it is true that clients who have a urinary catheter in place have less risk for skin breakdown due to incontinence, this is an invasive procedure that poses significant risks. The catheterization of the bladder can introduce bacteria into the bladder, creating a risk for bacteremia, a life-threatening bacterial infection of the blood.

A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought her standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take? A. Check that the client lifts the walker and then places it down in front of her. B. Walk in front of the client to guide her in moving the walker C. Have the client move one leg forward with the walker D. Make sure that the upper bar of the walker is level with the client's waist

A. Check that the client lifts the walker and then places it down in front of her. The client should lift the walker and advance it about 15 cm (6 in), then set it down. This allows her a wide base of support while she moves forward. B. As the client is ambulating, the nurse should walk slightly behind her and toward her side in case she needs assistance. C. The client should move the walker first, then move one foot up to the walker while bearing weight on the other foot and both arms, then move the other foot forward with the weight on the first foot and both arms. D. The top of the walker should be just below the level of the client's waist. She should stand in the center of the walker and grasp the handgrips on either side, with her elbows bent about 30°.

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, RR 24/min, BP 132/76 mm Hg, and T 36.8C (98.2F). Which of the following actions should the nurse perform? A. Complete a neurological check B. Administer the prescribed PRN antihypertensive medication C. Increase the client's fluid intake D. Hold the client's evening dose of digoxin

A. Complete a neurological check Neurological assessment is an appropriate nursing intervention when a client displays sudden confusion. Sensory alterations can occur when a client is experiencing multiple sensory stimuli and can result in inappropriate sensory responses. Tolerance to stimuli may be affected by fatigue and emotional and physical well-being.

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? SATA A. Report of feeling pressure B. Tenderness over the symphysis pubis C. Distended bladder D. Voiding 30mL frequently E. Dysuria

A., B., C., D. A. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a report of feeling pressure. B. Clinical findings of urinary retention include tenderness over the symphysis pubis. C. Clinical findings of urinary retention include a distended bladder. D. Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine. E. Dysuria, or painful burning with urination, is not a finding associated with urinary retention.

A nurse is preparing to suction a client who has tracheostomy. Identify the sequence of actions the nurse should take. Apply suction while rotating the catheter. Adjust the suction. Hyperoxygenate the client. Assess for secretion clearance. Don sterile gloves. Insert the catheter without suction. Check the function of the suction catheter.

Adjust the suction. Don sterile gloves. Check the function of the suction catheter. Hyperoxygenate the client. Insert the catheter without suction. Apply suction while rotating the catheter. Assess for secretion clearance. First, the nurse should adjust the suction, then don sterile gloves. Next, the nurse should check the function of the suction catheter by suctioning a small amount of solution into the tubing, then ask a peer to hyperoxygenate the client using a manual resuscitation bag valve mask connected to oxygen. The nurse should insert the suction catheter without suction and then apply suction for no more than 10 seconds while rotating the catheter. Finally, the nurse should assess for clearance of secretions.

A nurse is teaching a client who has diabetes about which dietary source should provide the greatest percentage of calories. Which of the following statements indicates the client understanding the teaching? A. "Most of my calories each day should be from fats." B. "I should eat more calories from complex carbohydrates than anything else." C. "Simple sugars are needed more than other calorie sources." D. "Protein should be my main source of calories."

B. "I should eat more calories from complex carbohydrates than anything else." The client who has diabetes should consume the majority of calories from complex carbohydrates, such as whole grains, fruits, and vegetables. A. The client who has diabetes should limit the intake of fats. C. The client who has diabetes should limit intake of simple sugars, such as foods containing sucrose. D. The client who has diabetes should consume 10% to 35% of total calories from protein sources.

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will walk briskly for 30 minutes before bedtime." B. "I will no longer have a glass of wine before bedtime." C. "I will have a cup of hot cocoa immediately before bedtime." D. "I will do my muscle relaxation techniques each afternoon."

B. "I will no longer have a glass of wine before bedtime." The client should limit or avoid alcohol consumption in the late afternoon and evening. Alcohol can act as a diuretic and cause the client to wake during sleeping hours to urinate. Alcohol also interrupts the sleep cycle and can make it difficult to stay asleep or return to sleep after awakening. A. The client should avoid exercising right before bedtime because this can stimulate him rather than relax him. If the client wants to exercise in the evening, it should be at least 2 to 3 hr before bedtime, so that the body has time to cool down and maintain a state of fatigue that promotes relaxation. C. The client should limit or avoid caffeine consumption before bedtime. Caffeine can act as a diuretic and cause the client to wake during sleeping hours to urinate. D. Muscle relaxation helps release tension. Stress can make the client have difficulty falling asleep, awaken periodically during the sleep cycle, and sleep too much without adequately resting. The client should perform relaxation exercises at bedtime to promote sleep.

A nurse is filling out an incident report after finding a client lying on the floor. Which of the following information should the nurse include? A. "The client attempted to climb over the side rails and fell." B. "The client was lying on the floor next to his bed." C. "The client was restless and trying to get out of bed all evening." D. "The presence of a bed alarm could have prevented the client from falling."

B. "The client was lying on the floor next to his bed." In an incident report, the nurse should only document what she actually witnessed, along with the date, time, place, and any other actual facts about the incident. A., C. Speculation about actions the nurse did not witness is not part of an incident report. D. Information about preventive measures is not part of an incident report. The facility's risk managers can later determine procedures to implement to prevent such incidents in the future.

A nurse is teaching an older client who has left-sided weakness about cane use. Which of the following instructions should the nurse include? A. "Hold the cane with your left hand." B. "When walking, move your left foot forward first." C. "Move the cane forward 18 inches with each step." D. "Keep your elbow straight when you hold the cane."

B. "When walking, move your left foot forward first." The client should move her weaker (left) foot with the cane first, then bring her stronger leg forward ahead of the cane and the weaker foot. A. The client should hold the cane with her stronger (right) hand. C. The client should move the cane forward 30.5 cm (12 in) with each step. Moving it too far forward increases her risk of falling. D. The client should keep her elbow slightly flexed when she uses her cane.

A nurse is providing teaching to a client who has neutropenia. Which of the following information should the nurse include in the teaching? A. Eat plenty of fresh fruits and vegetables B. Avoid crowds C. Perform mild exercise, such as gardening D. Take temperatures weekly

B. Avoid crowds The nurse should inform the client to avoid crowds due to his suppressed immune system. A. The nurse should inform a client who is neutropenic to avoid fresh fruits and vegetables due to the bacteria they can carry. C. The nurse should instruct the client to avoid gardening due bacteria contained in the soil. D. A client who is neutropenic can experience a 1° increase from his baseline temperature, even in the presence of infection. Therefore, the nurse should recommend the client take his temperature at least once daily.

A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site? A. Blistering B. Erythema C. Eschar D. Absence of pain

B. Erythema Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat. A. Blistering is an indication of a superficial partial thickness burn, involving injury to the upper third of the dermis. These injuries also are pink and moist, blanch to pressure and are very painful. C. Eschar is seen in clients who have a full thickness wound involving the epidermis and dermis. This is dead tissue that must be removed for healing to occur D. A thermal injury that is not painful can be classified as a deep full-thickness burn which extends into muscle, bone, or tendons.

A nurse is teaching a client who has cholecystitis about required dietary modifications. The nurse should include which of the following foods as appropriate for the client's diet? A. Creamed chicken B. Roasted turkey C. Ice cream D. Macaroni and cheese

B. Roasted turkey Roast turkey is a low-fat protein that is an appropriate choice for inclusion in the client's diet. Low-fat food decreases stimulation of the gallbladder, thereby reducing associated symptoms. A. The total amount of fat in the diet should be reduced. Creams should be avoided to reduce the symptoms associated with cholecystitis. B. Ice cream and other whole-milk products should be avoided to reduce the symptoms associated with cholecystitis. D. Macaroni and cheese should be avoided to reduce the symptoms associated with cholecystitis.

A nurse is documenting in a client's medical record. Which of the following abbreviations is appropriate for the nurse to use? SATA A. MSO4 B. bid C. 30 mL D. .2 mg E. Q.D

B., C. A. This abbreviation is incorrect because it can be confused with other medications, such as morphine sulfate, or magnesium sulfate. The nurse should write medication names out to reduce the risk for error. D. Doses less than 1.0 should have a leading zero (0.2 mg), and doses should not have trailing zeros (2.0 mg) because of the potential for making dosage errors (giving 2 mg instead of 0.2 mg, and giving 20 mg rather than 2.0 mg). E. This abbreviation is listed on the "do not use" list. This abbreviation is intended to mean "every day." It is incorrect because it is confused with Q.O.D., which is intended to mean "every other day." Write "daily" to reduce the risk for error.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan of prevent pulmonary complications? A. Perform ROM exercises B. Place suction equipment at the bedside C. Encourage the use of an incentive spirometer D. Administer an expectorant

C. Encourage the use of an incentive spirometer. Incentive spirometry expands the lungs and promotes gas exchange after surgery which can help prevent pulmonary complications. A. This is not indicated to prevent pulmonary complications, but early ambulation is helpful to promote lung expansion and remove secretions. B. Suction equipment should be readily available if needed, but its presence does not prevent pulmonary complications. D. Administering an expectorant is not indicated to prevent pulmonary complications, but the nurse should encourage the client to cough and deep breathe.

A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on effective learning with this client, which of the following interventions should the nurse use? A. Ask the client to perform a return demonstration of insulin injection. B. Review the action of insulin therapy. C. Explore the client's feelings about dietary modifications. D. Have the client practice blood-glucose monitoring using a glucometer.

C. Explore the client's feelings about dietary modifications. This teaching intervention allows the client to express his acceptance of this change and focuses on affective learning. A. This teaching intervention focuses on psychomotor learning. B. Cognitive learning D. Psychomotor learning

A nurse in a provider's office returns a telephone call by the end of the day, as promised, to a client who is worried about the outcome of a laboratory test. The nurse is demonstrating which of the following ethical principles? A. Autonomy B. Justice C. Fidelity D. Nonmaleficence

C. Fidelity The nurse demonstrates the ethical principle of fidelity by keeping a promise. A. The nurse demonstrates the ethical principle autonomy when supporting the client's right to make decisions about care. B. The nurse demonstrates the ethical principle of justice when treating everyone fairly. D. The nurse demonstrates the ethical principle of nonmaleficence when action is taken to prevent harm to the client.

A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? A. "Use a natural membrane condom rather than a polyurethane condom." B. "You may use a condom more than once." C. "Use an oil-based lubricant when you use a condom." D. "Female condoms can help prevent transmission of sexually transmitted viruses."

D. "Female condoms can help prevent transmission of sexually transmitted viruses." The client who uses a female condom can prevent sexually transmitted viruses when the polyurethane or nitrile sheath is placed in the vagina. A. The client should use a polyurethane condom instead of a natural membrane condom because natural condoms do not protect the client from HIV infection. B. The client should use a new condom with every sexual encounter for effective prevention of transmission of an infection and to decrease the risk of breaking or slipping off. C. The client should not use an oil-based lubricant as the oil can damage the condom. The client should use a water-based lubricant.

A nurse is providing discharge teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statements indicates an understanding of the teaching? A. "I will apply elastic bandages to cuts." B. "I will use dishwashing gloves when cleaning the dishes." C. "I will buy balloons for my son's birthday." D. "I will use ink pens for writing."

D. "I will use ink pens for writing." The client understands pencil erasers contain latex and should use pens for writing instead. A. The client needs further instruction because elastic bandages contain latex. B. The client needs further instruction because dishwashing gloves contain latex. C. The client needs further instruction because balloons contain latex.

A nurse is providing teaching to a client who has a new colostomy. Which of the following information should the nurse include in the teaching? A. "You can expect fecal output within 24 hours." B. "You will need to increase your dietary intake of raw vegetables." C. "You can expect the stoma to be purplish in color for the first week." D. "You may experience a small amount of bleeding around the stoma."

D. "You may experience a small amount of bleeding around the stoma." A small amount of bleeding around the stoma and its stem can occur. However, the client should report an increase in bleeding to the surgeon. A. The client should expect fecal output from the colostomy stoma in 2 to 3 days. B. Many raw vegetables, such as onions, cucumbers, mushrooms, broccoli, cabbage, and cauliflower, increase gas and odor. The client should limit or avoid consuming these foods. C. A stoma that deepens in color to a purplish hue can indicate ischemia. The client should report this finding to the surgeon.

A nurse is preparing to administer the hepatitis B vaccine to a client. Which of the following techniques should the nurse to locate the deltoid muscle? A. Locate the center of the arm between the elbow and the shoulder. B. Find the center of the anterior aspect of the thigh. C. Locate the middle third of the anterior thigh between the greater trochanter of the femur and the lateral femoral condyle. D. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm.

D. Place one finger across the acromion process and measure 3 fingerbreadths below to the midpoint and center of the lateral aspect of the upper arm. This identifies the deltoid muscle, into which the nurse should inject the vaccine. A. Locating the center of the arm does not give the nurse specific location for injecting the vaccine. B. This identifies the rectus femoris site, not the deltoid site. C. This identifies the vastus lateralis site, not the deltoid site.

A nurse is reviewing the medication administration records from the previous shift. Which of the following findings should indicate to the nurse a need for an incident report? A. A client received gentamicin intermittent IV bolus over 1 hr. B. A nurse used a 25-gauge 3/8 inch needle to administer a heparin injection C. A nurse injected Demerol IM into the vastus lateralis site of adult. D. A client received a crushed bupropion XL tablet mixed with applesauce.

D. A client received a crushed bupropion XL tablet mixed with applesauce. Extended or sustained release medications are intended to release medication levels over a long period of time to sustain therapeutic relief. Crushing, breaking, or chewing an extended release medication releases the medication at once into the bloodstream and could be life-threatening. Mixing this medication in applesauce deviates from standard of care and requires the nurse to complete an incident report. A. The nurse should administer the dose of gentamicin via intermittent IV bolus diluted in 50 to 200 mL of 0.9% sodium chloride over 30 to 60 min to prevent injury. B. The nurse should use a 25- or 26-gauge, ½ to 5/8 inch needle when administering a subcutaneous heparin injection. The nurse should neither aspirate nor massage the site after injecting the medication into the fatty layer of the abdomen, 5.1 cm (2 in) away from the umbilicus. The nurse should hold gentle pressure over the site for 1 to 2 min after administering the heparin. C. The nurse should use a large, well developed muscle for IM injections. The vastus lateralis is the best site because it has the largest muscle mass and does not have major blood vessels or nerves in the area.

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the client to avoid while taking this medication? A. Milk B. Orange juice C. Coffee D. Grapefruit juice

D. Grapefruit juice Grapefruit juice increases blood levels of verapamil, a calcium channel blocker, by inhibiting its metabolism. The excess amount of medication can intensify the medication's hypotensive effects, putting the client at risk for syncope and dizziness. A. Milk has no known effect on the metabolism of verapamil; therefore, this is a safe beverage for the client to drink while on this medication. B. Orange juice has no known effect on the metabolism of verapamil; therefore, this is a safe beverage for the client to drink while on this medication. C. Although coffee consumption should be limited while taking verapamil, it does not have to be avoided.

A nurse is teaching a newly hired group of assistive personnel (AP) about infection-control measures on the unit. It is crucial for the nurse to remind the APs that which of the following is the most effective way to prevent the spread of pathogens during client care? A. Properly disposing of contained equipment B. Discarding used syringes in appropriate containers C. Changing soiled linens daily for clients who have draining wounds D. Performing hand hygiene frequently and consistently

D. Performing hand hygiene frequently and consistently The greatest risk to all clients and staff on the unit is infection from cross contamination; therefore, the priority action is hand hygiene. It is one of the most important and effective ways to prevent pathogen transmission. It applies to every health care setting and is a consistent imperative during client care. A. Some clients and staff are at risk for infection from improper disposal of contaminated equipment; however, another action is the priority. B. Some clients and staff are at risk for infection from improper discarding of used syringes; however, another action is the priority. C. Some clients and staff are at risk for infection from soiled linens; however, another action is the priority.

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? A. Deflate the catheter balloon using a sterile syringe B. Measure and document the urine in the drainage bag C. Remove the tape or device securing the catheter to the client's thigh D. Position the client supine

D. Position the client supine The first action the nurse should take using the nursing process is to place the client in a supine position. This permits adequate visualization and assessment of the perineal area and promotes client comfort and relaxation. A., B., C. This is an appropriate action, but not the first action the nurse should take.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first ? A. Administer O2 at 2L/min B. Administer prescribed analgesic med C. Encourage coughing and deep breathing D. Raise the head of the bed

D. Raise the head of the bed Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive. A. The nurse should assess the client further and implement less invasive interventions before applying oxygen at 2 L/min. B. Pain management promotes increased participation by the client in coughing and deep breathing, frequent position changes and use of the incentive spirometer, but this is not the first action the nurse should take. C. Coughing and deep breathing promotes lung expansion and prevents respiratory infection, but these actions are not effective immediately in increasing oxygen saturation.

A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client. Which of the following actions should prompt the charge nurse to intervene? A. The nurse initiates the feeding after aspirating 50 mL of gastric residual. B. The nurse irrigates the NG tube with tap water after feeding. C. The nurse administers the feeding through a syringe barrel by gravity. D. The nurse allows the client to rest in a supine position during feeding.

D. The nurse allows the client to rest in a supine position during feeding. The nurse should elevate the head of the bed to a minimum of 30° to prevent aspiration from reflux during feedings. A. The nurse should withhold the feeding if the residual exceeds 100 mL or the amount specified by facility policy. It is generally safe to proceed after finding 50 mL of gastric residual. B. It is appropriate to flush the tubing with 50 to 100 mL of water after feedings to prevent clogging. The stomach is not sterile, so tap water is acceptable. C. After removing the plunger, the nurse should pour the formula into a 60-mL syringe and allow it to flow by gravity. The nurse can adjust the flow by raising or lowering the syringe.

A nurse in a long-tern care facility enters the day room and finds the window curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the emergency actions the nurse must take. Activate the fire alarm. Extinguish the fire. Close the door. Remove the clients from the room.

Remove the clients from the room. Activate the fire alarm. Close the door. Extinguish the fire. In the event of a fire, it is helpful to recall the mnemonic RACE to prioritize the actions to take: R - Rescue and remove the clients, A - Activate the alarm, C - Confine the fire, and E - Extinguish the fire. The nurse's priority action is to remove the clients from the room. The nurse should then sound the fire alarm and close the door to confine the fire. Finally and if possible, the nurse should extinguish the fire.