FUNDS preassessment quiz VATI

15. A nurse is calculating a clients intake and output for an 8 hr shift. The clients intake included 1000 ML's 0.9% sodium chloride. IV, 16 ounce cup of coffee, 6 ounce of water, one 180 ML bowl of soup; 3 ounce of flavored gelatin, and 3 ounce of ice cream. How many ML should the nurse documents as the clients total intake for the shift? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

1720 ml

6. A nurse is assessing a client who is experiencing prosthetic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) A. Report a feeling pressure. B. Tenderness over the symphysis pubis C. Distended bladder. D. Voiding 30 ML's frequently. E. Dysuria

A,b,c,d Reports of feeling pressure is correct urinary retention is commonly seen clients diagnosed with prosthetic hypertrophy. Clinical findings of urinary retention include a feeling of pressure. Tenderness over the synthesis pubis is correct urinary retention is commonly seen clients diagnosed with prosthetic hypertrophy. Clinical findings of urinary retention. Include tenderness over the synthesis pubis. Distended batter is correct urinary retention is commonly seen clients diagnosed with prosthetic hypertrophy. Clinical findings of urinary retention include a distended bladder. Voiding 30 ML's frequently is correct urinary retention is commonly seen client diagnosed with prosthetic hypotrophy. Clinical findings of urinary retention include frequent voiding, 25 to 30 ML of urine.

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

A. Apply a moisture barrier ointment to the client skin. Skin that remains in contact with urine for prolong periods is at risk for maceration and breakdown. After cleansing and drying the client skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.

13. 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 action, should the nurse take? A. Check that the client lift the walker and then places it down in front of her. B. Walk in front of the client to guide her and moving the walker. C. Have the client move forward with walker. D. Make sure that the upper bar of the walker is level with the clients waste.

A. Check that the client lifts the walker and then places it down in front of her. The client should lift the walker in advanced about 15 cm (6 inches), then set it down. This allows her a white base of support washing, moves forward.

4. A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/MIN, respiratory rate 24/MIN, BP 132-76MMHG, and temperature 36.8°C(98.2°F). Which of the following actions to the nurse perform? A. Complete a neurological check. B. Administer the prescribed PRN anti-hypertensive medication. C. Increase the client fluid intake. D. Declines evening dose of digoxin.

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

22. A nurse is presenting a class about fall prevention to a group of assisted-living residence, which of the following statements by resident, best indicates and understanding of the teaching.? A. It is a good idea to use the handrails in the bathroom. B. I should use chairs without armrest. C. I should place a 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. Client should use them for added stability when changing positions.

19. A nurse is providing teaching for a client who is preparing for a below knee amputation. Which of the following statements is true, regarding the postoperative placement of a 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. Special pressure dressing will remain on Cushing 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 and exercise to prepare the client for prosthesis use

25. A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions the nurse should take. ( move the steps into the box on the right, placing them in the order of performance. Use all the steps) 1. Adjust the suction 2. Apply suction while rotating the catheter 3. Don sterile gloves 4. Check the function of the suction catheter 5. Insert the catheter without suction 6.hyperoxygenate the client 7. Assess for secretion clearance

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

21. The nurse is providing taken to a client who has neutropenia which of the following information should the nurse, including the teaching.? A. Plenty of fresh fruits and vegetables. B. Avoid crowds. C. Perform mild exercise, such as gardening. D. Take temperature weekly.

B. Avoid crowds. The nurse should inform the client to avoid crowds due to his suppressed immune system

8. A nurse is assessing a client following the application of an aqua Urmia 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.Escher 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 increase sensitivity to heat .

27. The 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 clients understanding the teaching.? A. Most of my calories, each day should be from fats. B. I should eat more calories from complex carbohydrates and anything else. C. Simple sugars are needed more than other sources. D. Protein should be my main source of calories.

B. I should eat more calories from complex carbohydrates and anything else. The client who has diabetes should consume the majority of calories from complex carbohydrates, such as whole grains, fruits, and vegetables

10. A nurse is teaching a client who reports insomnia about promoting restless sleep, which of the following statements should the nurse identify as an indication. The client understands the instructions.? A. I will walk brisk 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 caused the client to wake up 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 .

9. 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 clients diet. A. Creamed chicken B. Roasted turkey. C. Ice cream D. Macaroni and cheese.

B. Roasted chicken. Roast turkey is a low-fat protein that is an appropriate choice for inclusion in the client diet. Low-fat food decreases stimulation of the gallbladder, thereby reducing associated symptoms.

18. A nurse is filling out an instant report after finding a client line 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 laying 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 better could have prevented the client from falling.

B. The client was laying on the floor next to his bed In an incident report, the nurse should only document what she actually witnessed, along with the time, date, place, and any other actual facts about the incident

24. The nurse is teaching an ultra adult client who has left-sided weakness about can 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 cane first, then bring her stronger leg forward ahead of the cane and the weaker foot.

2. A nurse is a documenting in a clients medical record. Which of the following following abbreviations is appropriate for the nurse to use (select all that apply.) A. MSO4 B. bid C. 30mL D. .2mg E. Q.D.

B. bid C. 30mL

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

C. Encourage the use of an incentive spirometer. Incentive spirometry, expands the lungs and promotes gases change after surgery, which can help prevent pulmonary complications .

16. A nurse is coming for a client who has a new diagnosis of type one diabetes mellitus. To focus on effective learning with this client, which of the following interventions to 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 clients feelings about dietary modifications. D. Have the client practiced blood glucose monitoring using a glucometer.

C. Explore the clients feelings about dietary modifications. This teaching intervention allows the client to express his acceptance of this change and focuses on Affective learning

28. A nurse and a provider office returned the telephone call by the end of the day, as promised, to a client who was 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. Non-male

C. Fidelity The nurse demonstrates the ethical principle of Fidelity by keeping a promise

30. A nurse is reviewing the medication administration record from the previous shift. Which of the following findings should indicate to the nurse I need for an incident report? A. A client received gentle myosin intermittent IV bolus over one hour. B. a nurse used a 25 3/8 inch needle to administer a heparin injection C. A nurse, injected, Demerol I am into the vast lateral side of an adult. D. A client received a crushed propane XL tablet, mixed with applesauce.

D. A client received a crushed appropriate XL tablet, mixed with applesauce. Extended or sustained release medication's are intended to release medication levels over long period of time to sustain the therapeutic relief, crushing breaking or chewing and extended release medication, releases the medication at once into the bloodstream, and could be life-threatening mixing this medication and applesauce deviates from standard of care and requires the nurse to complete an incident report

7. A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections, which of the following statements to the nurse, including 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 using 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 nitro sheath is placed in the vagina

26. A nurse is providing teaching to a client who has hypertension and 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

D. Grapefruit Grapefruit juice increases blood levels of variability, 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.

1. A nurse is providing discharge, teaching to a client who was recently diagnosed with a latex allergy. Which of the following client statements indicates and 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 .

11. A nurse is teaching a newly hired group of assistive personnel 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 contaminated equipment. B. Discarding use 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 wrist 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 voice to prevent pathogen transmission. It applies to every healthcare setting and is a consistent imperative during client care .

3. A nurse is preparing to administer the hepatitis B vaccine to a client which of the following techniques should the nurse use to locate the deltoid muscle. A. Locate the center of the arm between the elbow and the shoulder. B. The center of the interior aspect of the thigh. C. Locate the middle, third of the anterior thigh between the greater cancer of the femur and the lateral femoral condyle. D. Place one finger across the acromion process, and measure three finger breaths, below the midpoint and center of the lateral aspect of the upper arm.

D. Place one finger across the acromion process, and measure three finger breaths, below 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

20. A nurse is preparing to discontinue a clients dwelling urinary catheter which of the following action 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 the device secure the catheter to the client. D. Position the client supine.

D. Positioned 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.

12. A nurse is caring for a client who has returned to the unit following a surgical procedure. The clients oxygen saturation is 85% which of the following action should the nurse take first? A. Administer oxygen at 2 L per minute. B. Administer prescribed analgesic medication. C. Encouraged coughing and deep breathing. D. Raise ahead of the bed.

D. Raised ahead 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 should take, and is the least invasive.

23. A charge nurse observes a nurse administer intermittent tube feedings via an NG tube to a client which of the following action 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 tapwater after feeding. C. The nurse administer 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

5. 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 polished 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. Rationale : a small amount of bleeding around the stoma and its stem can occur. However, the client should report an increased in bleeding to the surgeon.

29. A nurse in a long-term 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. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Activate the fire alarm Extinguish the fire Close the door Remove the clients from the room

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