VATI Med-Surg Post-Assessment

A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings should the nurse report to the provider? A. There is 2 cm (0.79 in) of water in the water seal chamber. B. There is continuous bubbling in the suction chamber. C. The fluid in the collection chamber is draining at 75 mL/hr. D. The level in the water seal chamber rises when the client inhales.

C. The fluid in the collection chamber is draining at 75 mL/hr. An increase in drainage greater than 70 mL/hr is an indication the client might be bleeding. The nurse should report this finding to the provider.

A nurse is caring for a client who has multiple sclerosis and is unable to maintain a grip on eating utensils. Which of the following referrals should the nurse make? A. Speech-language pathologist B. Physical therapist C. Registered dietitian D. Occupational therapist

D. Occupational therapist Occupational therapists assist with developing a client's fine motor skills used for activities of daily living, such as eating, grooming, and hygiene.

A nurse is reviewing the medical record of a client who has a prescription for liraglutide. Which of the following findings should the nurse identify as a contraindication to this medication? A. History of thyroid cancer B. Concurrent use of metformin C. Blood glucose 200 mg/dL D. Albumin 3.8 g/dL

A. History of thyroid cancer The nurse should identify a personal or family history of thyroid cancer as a contraindication to taking liraglutide and notify the provider. Other contraindications to receiving this medication can include type 1 diabetes mellitus, diabetic ketoacidosis, and a history of suicidal thoughts or attempts.

A nurse is caring for four clients. Which of the following clients is at risk for skin breakdown? A. A client who has a prealbumin level of 8.6 mg/dL B. A client who has a glycosylated hemoglobin of 4.2% C. A client who has a high-density lipoprotein of 70 mg/dL D. A client who has a WBC count of 8,000 mm3

A. A client who has a prealbumin level of 8.6 mg/dL A client who has a low prealbumin level may be experiencing malnutrition, a risk factor for skin breakdown. The expected reference range of prealbumin is 15 to 36 mg/dL. Decreased prealbumin levels can also be present in liver damage, burns, and inflammation.

A nurse is planning dietary teaching for a client who has cholecystitis. The nurse should instruct the client to limit intake of which of the following foods? A. Broccoli B. Ripe bananas C. Cooked apples D. Barley

A. Broccoli Clients who have cholecystitis should avoid gas-producing foods, which include broccoli and cabbage. The client should also consume a diet high in fiber and low in fat.

A nurse is preparing to administer an IV bolus medication for a client who has an implanted port. Which of the following actions should the nurse take? A. Check the blood return B. Flush the catheter using a 3 mL syringe C. Cleanse the implanted port insertion site with alcohol D. Place the client in Trendelenburg position

A. Check the blood return Before infusing a medication through an implanted port, the nurse should check for blood return. If there is no blood return, the medication should be withheld until patency can be established and needle placement is confirmed. The nurse should flush the catheter using a 10 mL syringe with 5 mL heparin 10 units/mL or 0.9% sodium chloride after each use and at least once per month. The nurse only needs to cleanse the implanted port insertion site with dressing changes and should use chlorhexidine gluconate solution rather than alcohol. The nurse should place the client supine or in the Trendelenburg position when changing the administration set or connectors of a central line to prevent air emboli.

A nurse is teaching a client who is to have external beam radiation therapy. Which of the following instructions should the nurse include? A. Dry the affected area in a patting motion after washing. B. Use a washcloth when cleaning the affected area. C. Limit sun exposure to the affected area to 30 min per day. D. Use over-the-counter burn cream on the affected area as needed.

A. Dry the affected area in a patting motion after washing. The nurse should instruct the client to gently wash the affected area each day, then use a patting motion to dry it, rather than rubbing, to reduce the risk of irritation. The nurse should instruct the client to use their hand rather than a washcloth when cleaning the affected area to reduce the risk of injury. The nurse should instruct the client to avoid sun exposure to the affected area to reduce the risk of injury. The client should wear clothing to cover the affected area and remain in the shade when possible. The nurse should instruct the client to only use creams that are prescribed by the provider to reduce the risk for irritation or injury to the affected area.

A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect? A. Elevated central venous pressure B. Presence of S3 ventricular gallop C. Elevated pulmonary artery wedge pressure D. Orthopnea at night

A. Elevated central venous pressure The nurse should expect a client who has right-sided heart failure to have an elevated central venous pressure due to right ventricular failure. Central venous pressure is the pressure in the vena cava, near the right atrium of the heart, which reflects the amount of blood returning to the heart. Presence of S3 ventricular gallop can be detected in clients who have left-sided heart failure due to altered ventricular filling. Pulmonary pressure increases in left-sided heart failure because of the increased pressure and volume of blood in the left ventricle. Orthopnea, or difficulty breathing when lying flat, is a manifestation of left-sided heart failure due to pulmonary congestion.

A nurse is caring for a client following a thoracentesis. Which of the following actions should the nurse take? A. Obtain a prescription for a chest x-ray. B. Instruct the client to take shallow breaths. C. Leave the puncture site uncovered. D. Position the client prone.

A. Obtain a prescription for a chest x-ray. The nurse should obtain a prescription for a chest x-ray to assess the client for a pneumothorax or a mediastinal shift, which can occur if the lung is punctured during the thoracentesis. Following a thoracentesis, the nurse should encourage the client to breathe deeply to promote lung expansion. Following a thoracentesis, the nurse should apply a dressing to the puncture site and monitor it for leakage or bleeding. The nurse should position the client on the unaffected side for 1 hr to promote healing of the pleural puncture site.

A nurse is caring for a client who has an intra-arterial blood pressure monitor. Which of the following actions should the nurse take? A. Position the transducer's stopcock at the level of the atrium. B. Set the pressure bag around the flush solution at 400 mm Hg. C. Ensure the system delivers 10 mL of solution per hour. D. Administer 5% dextrose in water through the flush system.

A. Position the transducer's stopcock at the level of the atrium. The nurse should position the transducer's stopcock on the pressure monitoring system at the level of the client's atrium to maintain accurate blood pressure readings. The nurse should maintain the pressure bag around the flush solution at 300 mm Hg to reduce the backflow of blood into the system and minimize the risk of clotting. The nurse should ensure that the flush system delivers 3 to 5 mL of solution per hour to reduce the backflow of blood into the system and minimize the risk of clotting. The nurse should administer 0.9% sodium chloride through the flush system to reduce the backflow of blood into the system and minimize the risk of clotting.

A nurse is teaching a female client who has recurrent urinary tract infections. Which of the following instructions should the nurse include? A. Wear loose fitting cotton underwear. B. Drink 1,500 mL of water per day. C. Use vaginal douches monthly. D. Choose spermicides if contraception is desired.

A. Wear loose fitting cotton underwear. The nurse should instruct the client to wear loose fitting cotton underwear to decrease irritation to the perineum, which can contribute to the development of urinary tract infections.

A nurse is caring for a client who has a Clostridium Difficile infection. Which of the following interventions should the nurse use to prevent transmission? A. Alcohol-based antiseptics B. N95 respirator C. Sterile gloves D. Eye protection

D. Eye protection Using protective equipment, such as a mask and goggles, can prevent accidental exposure if splashing or spraying of fecal material occurs. Other personal protective equipment used in the care of a client who has a C. difficile infection include a gown and gloves.

A nurse is caring for a client who is receiving radiation therapy to the neck. Which of the following client statements is the priority to report to the provider? A. "Foods do not taste the same." B. "I have had a fever for 2 days." C. "My mouth is dry all the time." D. "I always feel exhausted."

B. "I have had a fever for 2 days." When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature because it can be a manifestation of an infection. Bone marrow suppression and decreased immunity can occur with radiation therapy.

A nurse is assessing a client who is postoperative following surgery using general anesthesia. Which of the following findings is the priority to report to the provider? A. Client report pain as 5 on a scale of 0 to 10 B. A decrease in blood pressure from 130/72 to 110/68 mm Hg C. Absent bowel sounds D. Client report of nausea

B. A decrease in blood pressure from 130/72 to 110/68 mm Hg When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a decrease in blood pressure because this can be an indication of fluid volume deficit or hemorrhage.

A charge nurse is assigning the care of a client who has an internal radiation implant. Which of the following actions should the nurse take? A. Assign the client to a semi-private room with another client who has a fractured tibia. B. Assign the client to nurses who are not pregnant or trying to conceive. C. Instruct visitors that they must remain 3 feet away from the client. D. Instruct visitors that visits should be no longer than 60 min.

B. Assign the client to nurses who are not pregnant or trying to conceive. Radiation can be tetrogenic to fetuses. Staff who are pregnant or are trying to conceive should not be exposed to the client due to the risk of radiation exposure. The client who is receiving internal radiation through an implanted device requires a private room. This prevents accidental injury to another client due to the risk of radiation exposure. The charge nurse should instruct all visitors to remain at least 6 feet away from the client to avoid the risk of exposure to radiation. The nurse should instruct the visitors to limit visits to 30 min per day to decrease the risk of radiation exposure.

A nurse is monitoring a client who has a prescription for ciprofloxacin 400 mg IV every 12 hr. Which of the following manifestations should the nurse identify as an adverse effect of this medication? A. Constipation B. Anorexia C. Fever D. Myalgia

D. Myalgia The nurse should identify that myalgia is an adverse effect of ciprofloxacin and can be an indication that the client might be experiencing tendonitis, which could lead to tendon rupture. Other adverse effects can include dizziness, agitation, and confusion.

An occupational health nurse is preparing to teach a class on the prevention of back injuries to a group of workers in a factory setting. Which of the following interventions should the nurse include in the teaching? A. Bend at the waist when lifting an object from the floor. B. Hold the object being lifted close to the body. C. Keep feet close together when lifting. D. When moving objects from one location to another, keep legs stationary and twist at the waist.

B. Hold the object being lifted close to the body. The nurse should instruct the workers to keep objects being lifted close to the center of gravity by holding the object near the body. This reduces the strain on the lower back muscles and decreases the risk for injury. The nurse should instruct the workers to bend at the knees and use the stronger muscles in the legs when lifting objects from the floor. Bending at the waist increases back strain and can result in injury. The nurse should instruct the workers to maintain a wide base of support when lifting an object. This provides greater stability when lifting and reduces the risk of strain or injury to the back. The nurse should instruct the workers to move the legs and pivot the whole body as a single unit when moving objects from one surface to another. This reduces the strain on the back and can help prevent injury.

A nurse is assessing a client who is receiving hemodialysis. Which of the following findings is the nurse's priority to report to the provider? A. Nausea B. Hypotension C. Headache D. Diaphoresis

B. Hypotension When using the airway, breathing, and circulation priority framework, the nurse should recognize that hypotension is the priority finding to report to the provider for a client who is receiving hemodialysis. A client who is receiving hemodialysis is at risk for vasodilation due to the introduction of a warm fluid into the bloodstream, which can result in a drop in blood pressure.

A nurse is reviewing the medical record of an older adult client as a part of a fall risk assessment. Which of the following client conditions should the nurse identify as increasing risk for falls? A. Dermatitis B. Presbyopia C. Xerostomia D. Kyphosis

B. Presbyopia Presbyopia is a condition of farsightedness, which is commonly found in older adult clients. It can increase the risk for falls because the client has decreased near vision.

A nurse is caring for a client who has global aphasia following a cerebrovascular accident (CVA). Which of the following actions should the nurse incorporate into the client's care? A. Provide the client with two-step tasks B. Request a consult with the speech-language pathologist. C. Ask questions the client can answer with a simple "yes" or "no." D. Use a raised voice when speaking to the client.

B. Request a consult with the speech-language pathologist. The speech-language pathologist can recommend specific communication strategies for a client who has global aphasia. By identifying this need, the nurse is advocating for the client.

A nurse is caring for a client who is receiving the first dose of IV ampicillin and develops a rash and flushed skin and begins wheezing. Which of the following actions should the nurse take first? A. Notify the Rapid Response team B. Stop the infusion C. Give oxygen via nonrebreather facemask. D. Administer epinephrine.

B. Stop the infusion The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to stop the infusion. However, the nurse should keep the IV open and infuse 0.9% sodium chloride until epinephrine is available to administer.

A client who is newly diagnosed with cancer has been prescribed oral chemotherapy. The client tells the nurse, "I'm not sure if I want to take this medicine." Which of the following responses should the nurse make? A. "I think you should seriously consider the consequences of not going through with treatment." B. "You do not have to take any medications that you don't want to." C. "Tell me more about what is making you feel unsure about taking this medication." D. "Are you nervous about the side effects of chemotherapy?"

C. "Tell me more about what is making you feel unsure about taking this medication." This is an open-ended statement that allows the client to express their concerns about the treatment plan.

A nurse is teaching a client who has breast cancer about receiving radiation therapy. Which of the following statements should the nurse make? A. "You should expect each treatment session to last for about 1 hour." B. "You can expect to gain about 15 to 20 pounds during treatment." C. "You might develop a rash on the skin under your arm during therapy." D. "You will receive two or three sessions of radiation therapy in total."

C. "You might develop a rash on the skin under your arm during therapy." The nurse should instruct the client to expect radiation dermatitis, or a skin rash, near the axilla. This can range from redness of the skin to desquamation, or a peeling, puckered appearance. The nurse should teach the client to wash the affected skin with a mild soap and to use hydrophilic lotions to assist with keeping the skin dry. The client should also dry the skin gently, using a patting motion rather than rubbing.

A nurse is teaching a client who has a colostomy. Which of the following instructions should the nurse include? A. Increase dietary intake of cruciferous vegetables. B. Use a moisturizing soap when cleaning the peristomal area. C. Clip hair in the peristomal area before applying the barrier wafer. D. Place an aspirin tablet in the ostomy bag to decrease odor.

C. Clip hair in the peristomal area before applying the barrier wafer. Clipping the peristomal hair will make a smooth surface for the barrier wafer to adhere to and will help minimize the risk of infection.

A nurse is preparing to administer a unit of fresh frozen plasma (FFP) to a client. Which of the following actions should the nurse plan to take prior to the transfusion? A. Initiate an IV infusion of dextrose 5% in water. B. Ensure the FFP is compatible with the client's Rh status. C. Confirm the plasma compatibility with another nurse. D. Review liver function tests.

C. Confirm the plasma compatibility with another nurse. The nurse should confirm the plasma ABO compatibility with another nurse by verifying the client's identity and comparing the bag of FFP to the medical record to prevent an adverse reaction. The nurse should also check the expiration time on the FFP.

A nurse is assessing a client who is receiving IV levofloxacin through a peripheral catheter. The nurse notes edema, skin blanching, and tightness around the client's IV site. Which of the following actions should the nurse take? A. Aspirate the medication from the peripheral catheter. B. Decrease the IV infusion rate. C. Apply direct pressure to the affected extremity. D. Elevate the affected extremity after discontinuing the IV.

D. Elevate the affected extremity after discontinuing the IV. The nurse should identify that the client's IV is infiltrated and should stop the infusion, remove the IV, and elevate the client's affected extremity to decrease edema.

A nurse is obtaining vital signs for a client and notes muscular twitching of the wrist and fingers when inflating the blood pressure cuff. The nurse should identify this is a manifestation of which of the following electrolyte imbalances? A. Hyponatremia B. Hypokalemia C. Hypocalcemia D. Hypophosphatemia

C. Hypocalcemia A positive Trousseau's sign is an indication of hypocalcemia and is assessed by inflating a blood pressure cuff on the upper arm. Spasms of the hand and fingers when the blood pressure cuff is inflated indicate a positive Trousseau's sign. Manifestations of hypocalcemia can include muscle twitching, tingling, and numbness, which can lead to tetany. Manifestations of hyponatremia can include altered mental status, muscle cramping, seizures, and confusion. Manifestations of hypokalemia can include muscle weakness, orthostatic hypotension, and dysrhythmias. Manifestations of hypophosphatemia can include muscle pain and weakness, which can affect respiratory muscles and cause impaired ventilation.

A nurse is providing palliative care to a client who has cancer. Besides helping to relieve pain, which of the following interventions will improve circulation? A. Aromatherapy B. Therapeutic touch C. Massage therapy D. Music therapy

C. Massage therapy Massage therapy involves manipulating the client's muscles and soft tissue, which improves circulation and promotes relaxation. Massage can decrease pain in clients who have cancer. Light pressure should be applied. Aromatherapy involves the use of plant extracts and essential oils to promote relaxation, reduce anxiety, and relieve pain. Therapeutic touch involves moving the nurse's hand through the client's energy field to alleviate pain. Music therapy involves the use of music to promote relaxation.

A nurse is caring for a client who has a newly placed endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take? A. Empty moisture from the tubing into the cascade. B. Assess the client's respirations once every 8 hr. C. Perform mouth care once every 2 hr. D. Apply four-point restraints to the client.

C. Perform mouth care once every 2 hr. The nurse should perform mouth care once every 2 hr to reduce the risk for ventilator-associated pneumonia.

A nurse is preparing to perform a venipuncture for an older adult client who has a prescription for intravenous fluids. Which of the following actions should the nurse plan to take? A. Elevate the extremity above the heart. B. Shave the skin around the area. C. Cleanse the skin with vigorous friction, moving inward from site. D. Apply a warm compress to the extremity.

D. Apply a warm compress to the extremity. The nurse should apply a warm compress or wrap the client's extremity in a warm towel to dilate the vein. The compress can be applied to the entire extremity for 10 to 20 min. The nurse should place the client's extremity in a dependent position to promote venous dilation and facilitate insertion of the intravenous catheter. The nurse should not shave the client's skin prior to venipuncture because this can cause abrasions that can result in an infection. Hair can be clipped with scissors or an electric shaver if needed. Excessive friction can damage fragile skin and cause impaired tissue integrity; therefore, the nurse should cleanse the site with an antiseptic solution by swabbing 2 to 3 min in a circular motion, moving outward from the injection site.

A nurse on a telemetry unit is reviewing the medical record of a client who is taking digoxin. For which of the following findings should the nurse withhold the medication and notify the provider? A. Apical heart rate 72/min B. Atrial fibrillation C. Digoxin 1.5 ng/mL D. Potassium 3.1 mEq/L

D. Potassium 3.1 mEq/L A potassium level of 3.1 mEq/L is below the expected reference range of 3.5 to 5 mEq/L. The nurse should identify that hypokalemia increases the sensitivity of cardiac muscle to digoxin and can increase the risk for digoxin toxicity. Bradycardia is an adverse effect of digoxin; therefore, the nurse should obtain the client's apical heart rate for 1 min prior to administering digoxin. If the client's heart rate is less than 60/min, the nurse should hold the medication and notify the provider. The nurse should identify that digoxin is an antidysrhythmic medication used to treat atrial fibrillation. It is administered to slow conduction through the atrioventricular node to decrease heart rate and increase cardiac output. The nurse should identify that a digoxin level of 1.5 ng/mL is within the expected reference range of 0.8 to 2 ng/mL. Toxic digoxin levels are greater than 2.4 ng/mL and can result in bradycardia and ventricular dysrhythmias.

A nurse is providing teaching to a client who has urinary incontinence and is beginning a bladder retraining program. Which of the following instructions should the nurse include? A. Perform intermittent self-catheterizations at bedtime. B. Limit fluid intake to 1,000 mL per day. C. Increase the amount of time between urination by 5 min when not having urgency D. Run water in the sink prior to toileting.

D. Run water in the sink prior to toileting. The nurse should instruct the client to run water prior to toileting. The sound of the running water can trigger the client's urge to urinate. Intermittent self-catheterization is a technique used for clients who have difficulty with complete bladder emptying. Limiting fluid intake can result in concentrated urine and increases the risk for urinary tract infections. The nurse should encourage the client to drink 1,500 to 1,600 mL of fluid per day, which should keep the urine dilute and promote healthy kidney function. The client should establish a new interval schedule by increasing the amount of time between urination by 10 to 15 min beyond the last interval.