VATI Fundamentals Post-Assessment
A nurse administers NPH insulin to a client. Which of the following entries should the nurse make in the client's medical record? A. NPH insulin, Z-track, at 1200 to right ventrogluteal site B. NPH insulin given IV push prior to breakfast C. 8 units NPH insulin, subcutaneous, right lateral upper thigh at 0700 D. 8 units NPH insulin injected at 15-degree angle to forearm
8 units NPH insulin, subcutaneous, right lateral upper thigh at 0700 Correct documentation of medication administration includes the medication's name, dose, route, site, and time. When it is a medication that requires injection site rotation, such as insulin, it is important to document the site each time.
A nurse is assessing four clients. Which of the following clients should the nurse identify as a potential candidate for a prescription for mitten restraints? A. A client who is restless and sits up in a chair during the night B. A client who has fallen during admission C. A client who is verbally abusive and refuses medication D. A client who has dementia and has removed their enteral feeding tube repeatedly.
A client who has dementia and has removed their enteral feeding tube repeatedly Clients who have confusion and repeatedly remove or try to remove medical devices might require mitten restraints to protect themselves from injury. However, the nurse should exhaust alternative methods prior to requesting a restraint prescription.
A nurse provides a medical interpreter to convey discharge instructions to a client who speaks a different language than the nurse. This action is an example of which of the following ethical values? A. Advocacy B. Nonmaleficence C. Veracity D. Justice
A. Advocacy Advocacy is the ethical principle of supporting the client in every situation. The nurse supports this client by using a medical interpreter to ensure that the client understands the discharge teaching. Nonmaleficence is a commitment to do no harm. Although this principle is essential to the practice of nursing, this action is not an example of nonmaleficence. Veracity is telling the truth. Although this principle is essential to the practice of nursing, this action is not an example of veracity. Justice is fairness in care delivery to all clients in order to ensure each client's needs are met. Although this principle is essential to the practice of nursing, this action is not an example of justice.
A nurse is reviewing a medical administration record for a client and discovers that an incorrect medication was just administered. Which of the following actions should the nurse take first? A. Check the client's vital signs B. Complete an incident report. C. Notify the client's provider. D. Document a description of the incident.
A. Check the client's vital signs The first action the nurse should take when using the nursing process is to assess the client for any adverse effects of receiving the incorrect medication.
A nurse is administering medications to a client who has a feeding tube. Which of the following actions should the nurse take? A. Flush the tube after administering each medication. B. Add medications to the tube feeding. C. Crush enteric-coated medications. D. Administer multiple medications together.
A. Flush the tube after administering each medication. The nurse should flush the client's feeding tube with 15 to 60 mL of water after administering multiple medications to prevent the tube from clogging. The nurse should not add medications to tube feedings to ensure the client receives the medication. The nurse should not crush enteric-coated medications because this causes the medication to be absorbed too soon. The nurse should administer one medication at a time to ensure the client receives each medication and to reduce the risk of a medication interaction.
A nurse is inserting an indwelling urinary catheter for a client and notes that the catheter has entered the client's vagina. Which of the following actions should the nurse take? A. Leave the catheter in place as a landmark to guide correct placement. B. Inflate the balloon to test its integrity. C. Prepare to irrigate the catheter. D. Cleanse the perineal area with a saline solution.
A. Leave the catheter in place as a landmark to guide correct placement. If no urine appears after inserting an indwelling urinary catheter, it might be in the vagina. The nurse should obtain a new sterile catheter to insert but can leave the catheter in place to guide placement of the new catheter. The nurse should not irrigate the indwelling catheter because this can result in an infection. Prior to insertion of an indwelling urinary catheter, the nurse should cleanse the perineal area with an antiseptic solution. Testing the balloon serves little purpose prior to catheter insertion, and it can cause damage and possible trauma on insertion. After confirming that the indwelling urinary catheter is draining urine and is fully inside the bladder, not the vagina, the nurse inflates the balloon to ensure that the catheter stays in place.
A nurse is assessing a female client for a possible breast mass. Which of the following actions should the nurse take? A. Palpate the breasts using finger pads while the client is supine. B. Palpate the breasts while the client is standing with their hands on their hips. C. Palpate the breasts while the client is standing and leaning forward. D. Palpate the breasts in a horizontal motion while the client is supine.
A. Palpate the breasts using finger pads while the client is supine. The nurse should use their finger pads to palpate the breasts while the client is supine.
A nurse is performing a home safety assessment for a client who had a stroke. The nurse note that the stairs in the client's home are in disrepair and pose a safety risk. The client states, "I cannot afford to have the stairs repaired." Which of the following actions should the nurse take? A. Refer the client to a social worker. B. Provide the client with information about the American Red Cross. C. Ask the client's provider to postpone discharge until the stairs are repaired. D. Recommend a long-term care facility for the client.
A. Refer the client to a social worker. The nurse should refer the client to a social worker, who can assist a client who is having financial difficulties. The social worker can find resources to repair the stairs. The American Red Cross is a nonprofit organization that provides preparedness education and relief in the event of a disaster. There is no medical indication that warrants postponing the client's discharge. A long-term care facility is indicated for clients who are no longer able to perform their own activities of daily living. There is no indication that warrants recommending a long-term care facility for the client.
A nurse is assessing a client following IM administration of an antibiotic. Which of the following findings is the nurse's priority? A. Report of throat swelling B. Swelling at the injection site C. Report of itching on the chest D. Itchy raised rash on the back
A. Report of throat swelling When using the airway, breathing, and circulation approach to client care, the nurse determines that the priority finding is swelling of the airway. A choking sensation or throat swelling indicates a severe allergic response that can progress quickly to anaphylaxis. The nurse should prepare to administer epinephrine to the client.
A nurse is caring for a client who has an NG tube for decompression and has observed no output from the tube over the past 2 hr. Which of the following actions should the nurse take? A. Verify the placement of the NG tube. B. Remove the NG tube. C. Place the client in Trendelenburg position. D. Apply a clamp to the air vent.
A. Verify the placement of the NG tube. The nurse should verify the placement of the NG tube by obtaining an abdominal x-ray.
A nurse discovers a fire in a client's room in a wastebasket where some isopropyl alcohol was discarded. Which of the following types of fire extinguisher should the nurse use to put out the fire? A. A B. B C. C D. K
B A type B fire extinguisher is appropriate for putting out flammable liquid and gas fires. Disinfectant solutions, such as isopropyl alcohol, are highly flammable liquids. A type A fire extinguisher is appropriate for putting out paper, upholstery, cloth, wood, and rubbish fires. A type C fire extinguisher is appropriate for putting out electrical fires. A type K fire extinguisher is appropriate for putting out fires in kitchens, such as in deep fryers in restaurants.
A nurse is assessing a client for peripheral edema. Which of the following actions should the nurse take? A. Assess the client's skin turgor. B. Check the client's feet. C. Check the client's peripheral pulses. D. Assess the client's ability to ambulate.
B. Check the client's feet. The nurse should assess the client's feet to determine the presence of edema, such as swollen, shiny, or taut skin. Pitting edema is assessed by pressing a finger on the edematous area. Pitting edema in the extremities is a manifestation of fluid-volume excess. The nurse should assess the client's skin turgor to evaluate for manifestations of fluid volume deficit. The nurse should check the client's peripheral pulses to evaluate for manifestations of impaired circulation. The nurse should assess the client's ability to ambulate to evaluate for manifestations of impaired mobility.
A nurse is caring for a client who has an abdominal binder following surgery. Which of the following assessments is the nurse's priority? A. Inspect the surgical wound for manifestations of infection. B. Evaluate the client's ability to perform incentive spirometry. C. Observe for manifestations of circulatory compromise distal to the binder. D. Assess the client's discomfort level on a scale of 0 to10.
B. Evaluate the client's ability to perform incentive spirometry. When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority assessment is evaluating whether the abdominal binder is compromising the client's respiratory status by preventing deep breathing. Observing the client using the incentive spirometer will provide observational evidence of the client's ability to perform deep breathing exercises to reduce the risk of atelectasis.
A nurse is caring for a client who is 3 days postoperative and requests a nonpharmacological measure for relieving acute pain. Which of the following interventions should the nurse implement? A. Obtain a prescription for a patient-controlled analgesia (PCA). B. Instruct the client to use distraction. C. Administer a placebo to the client. D. Request a transdermal patch for the client.
B. Instruct the client to use distraction. The nurse should identify that distraction can be an effective intervention for reducing acute pain. Other nonpharmacological interventions include application of cold, repositioning, biofeedback, and music.
A nurse is performing a health screening for a client. Which of the following findings should indicate to the nurse that the client is at risk for coronary artery disease? A. Total cholesterol 196 mg/dL B. Triglyceride 180 mg/dL C. High-density lipoprotein (HDL) 56 mg/dL D. Low-density lipoprotein (LDL) 120 mg/dL
B. Triglyceride 180 mg/dL A triglyceride level of 180 mg/dL is outside the expected reference range of 40 to 160 mg/dL for a male client and 35 to 135 mg/dL for a female client, which places the client at risk for coronary artery disease. A total cholesterol level of 196 mg/dL is within the expected reference range of less than 200 mg/dL. Therefore, this finding does not place the client at risk for coronary artery disease. An HDL level of 56 mg/dL is within the expected reference range of greater than 45 mg/dL for a male client and greater than 55 mg/dL for a female client. Therefore, this finding does not place the client at risk for coronary artery disease. An LDL level of 120 mg/dL is within the expected reference range of less than 130 mg/dL. Therefore, this finding does not place the client at risk for coronary artery disease.
A nurse in an operating room is performing surgical hand hygiene. Which of the following actions should the nurse take? A. Scrub with soap 15 cm (6 in) above the elbows. B. Use a nail pick to clean the fingernails under running water. C. Keep the hands below the elbows when rinsing them. D. Scrub each finger using five strokes with a hand brush.
B. Use a nail pick to clean the fingernails under running water. Large amounts of micro-organisms can collect in dirt and organic material under fingernails. Scraping out this material and ensuring its disposal via running water is essential for surgical hand hygiene. Nurses performing surgical hand hygiene should scrub their hands and arms with soap up to 5 cm (2 in) above the elbows. Washing a wide area decreases the risk for contamination of the gown the nurse will don; however, it is not necessary to scrub that far above the elbows. Nurses performing surgical hand hygiene should keep their hands above the elbows at all times. This allows water to flow from the least to most contaminated areas. Nurses performing surgical hand hygiene should scrub the nails of one hand with 15 strokes. They should scrub their palms, the sides of their thumbs and fingers, and the back of each hand with 10 strokes. Friction helps loosen and remove any micro-organisms that adhere to the surface of the skin.
A nurse is assisting a provider with obtaining informed consent for surgery from a client who is anxious about having the procedure. Which of the following actions should the nurse take? A. Inform the client of the risks and benefits of the surgery. B. Use an interpreter if the client's spoken language is different than the provider's. C. Inform the client that signing the form makes the decision irreversible. D. Make sure the client has received an antianxiety medication before signing the informed consent form.
B. Use an interpreter if the client's spoken language is different than the provider's. If the provider does not speak the same language as the client, it is essential to have a medical interpreter present to make sure the client understands all aspects of informed consent. Providing information in the client's spoken language is essential in providing safe, competent nursing care.
A nurse is teaching a client who has a new in-the-ear hearing aid about how to care for the device. Which of the following client statements indicates an understanding of the teaching? A. "I'll turn my hearing aid on before I insert it into my ear." B. "I'll remove the ear mold from my hearing aid before I clean it." C. "I'll expect to replace the batteries once a week." D. "I'll clean the ear mold with isopropyl alcohol."
C. "I'll expect to replace the batteries once a week." The client should replace the batteries once a week to maintain efficient functionality of the hearing aid. To conserve battery power, the client should turn the hearing aid off or remove the battery when it is not in use. Before reinserting it, the client should make sure it is off and the volume is all the way down. This decreases the risk of loud, disturbing sound when the client reinserts it. After reinsertion, the client should gradually adjust the volume to one third to one half its maximum volume. Ear molds are not removable for in-the-ear-hearing aids. All of the components are inside the ear mold. Isopropyl alcohol can damage the hearing aid. The client should use a soft, damp cloth for cleaning the ear mold.
A nurse is caring for a client who asks the nurse to explain what advance directives are. Which of the following statements should the nurse make? A. "The health care proxy is a document that explains your wishes for care when you can no longer do so." B. "Be sure that your family agrees with your choices before preparing your advance directives." C. "The provider consults your living will in the event that you are unable to make health care decisions." D. "Be sure you know what you want to write in your advance directives, because you can't change them later."
C. "The provider consults your living will in the event that you are unable to make health care decisions." Living wills direct care when clients do not have the capacity to make decisions. The provider will review the client's living will and plan treatment according to the client's preferences. A health care proxy is a document that appoints another individual to make health care decisions for the client. Although the family is usually involved, along with the provider, in helping to decide a client's decisional capacity, no one else has to agree with the client's choices. The nurse should instruct the client that they can change their advanced directives at any time.
A nurse receives handoff report on several clients. Which of the following clients is the nurse's priority? A. A client who is postoperative following coronary artery bypass grafting and needs discharge teaching B. A client requiring education about a new prescription for treating asthma C. A client who has a decreased level of consciousness D. A client who is crying after receiving a terminal diagnosis
C. A client who has a decreased level of consciousness A client who has a decreased level of consciousness is unstable; therefore, this client is the nurse's priority and requires immediate action by the nurse.
A nurse is planning care for a clien who has urinary incontinence. Which of the following interventions should the nurse plan to include? A. Reduce fluid intake throughout the day. B. Assist the client to the bathroom once every 8 hr. C. Apply a moisture barrier as part of perineal care. D. Use powder after hygiene care to absorb moisture.
C. Apply a moisture barrier as part of perineal care. Skin barrier ointment or cream protects the skin from contact with urine. This action helps reduce the risk of skin breakdown due to incontinence. The nurse should not use powder because it can cause skin abrasions and impair skin integrity. The nurse should assist the client to the bathroom every 2 to 4 hr to reduce the risk of urinary incontinence. The nurse should encourage fluid intake to maintain the client's skin integrity. Reducing the client's fluid intake 2 hr before bedtime can reduce the incidence of incontinence during sleep.
A nurse is preparing to move a client who is immobile up in bed with the assistance of another nurse. Which of the following actions should the nurse plan to take? A. Position the feet and knees close together. B. Tighten the back muscles when lifting. C. Keep the back, pelvis, feet, and neck in alignment. D. Bend at the waist when lifting.
C. Keep the back, pelvis, feet, and neck in alignment. To reduce the risk of injury to their lower back, the nurse should align their neck, back, pelvis, and feet when lifting an object or moving a client. When lifting an object or moving a client, the nurse should establish a broad base of support by keeping their feet apart. This helps to increase stability and maintain center of gravity. The nurse should tighten their abdominal muscles, not the muscles in their back, to reduce the risk of injury to their lower back. The nurse should bend at their knees, not at their waist, when lifting or moving a client.
A nurse is caring for a client who is receiving PCA and reports a pain level of 8 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Inform the client that 2 to 3 doses of PCA equals one standard dose of medication. B. Reprogram the pump to increase the demand dose and shorten the time interval. C. Review the total dose of medication the client received. D. Encourage the client to have a family member push the button while the client sleeps.
C. Review the total dose of medication the client received. When clients report that analgesia is not controlling their pain, the nurse should troubleshoot the situation in several ways. The nurse should verify that they understand how to use the pump, verify how much medication they have received, check that the device is functioning as it should, and check that the IV catheter is in place and patent. If all these factors are as they should be, the nurse should notify the provider for further instructions for pain management.
A nurse at a health fair is performing screening assessments for older adult clients. Which of the following is the priority mental health assessment that the nurse should include? A. Delirium B. Dementia C. Alcohol use disorder D. Depression
D. Depression The greatest mental health risk for older adult clients is depression. Therefore, this is the priority assessment to include.
A nurse is admitting a client who is at risk for falls. Which of the following interventions should the nurse include in the client's plan of care? A. Keep all four side rails in the up position. B. Offer assistance with toileting every 4 hr. C. Place the client's personal possessions in the bedside closet. D. Have the client demonstrate how to use the call light.
D. Have the client demonstrate how to use the call light. The nurse should demonstrate use of the call light for the client and ask for a return demonstration to confirm the client's understanding. This ensures the client will be able to request assistance quickly and reduces the risk for falls. Evidence-based practice indicates that raised side rails can pose a safety hazard. Clients might still try to get out of bed by climbing over the rails, which can increase the risk of falling. The nurse should make rounds and offer the client assistance with elimination every hour from 0600 to 2200 and every 2 hr between 2200 and 0600 to decrease the incidence of falls. When an elimination need becomes urgent and the client does not have immediate assistance, a fall is possible when attempting to get out of bed. The nurse should place the client's personal possessions within easy reach to decrease the risk for falls.
A nurse is caring for a client who has vision loss. Which of the following intervention should the nurse implement to promote the client's independence while eating? A. Elevate the head of the client's bed during meals. B. Provide small-handle utensils. C. Instruct the client to rest 30 min prior to meals. D. Inform the client of the location of food on the plate.
D. Inform the client of the location of food on the plate. The nurse should use the time on a clock to describe the location of food on a client's plate. This can promote independence during meals for clients who have vision loss. Resting 30 min prior to eating can reduce the risk of aspiration in clients who have dysphagia. This action does not promote independence during meals for clients who have vision loss. The use of large-handle adaptive utensils can promote independence during meals for clients who have vision loss. Positioning the client with the head of the bed elevated reduces the risk of aspiration in clients who have dysphagia. This action does not promote independence during meals for clients who have vision loss.
A nurse in the emergency department is caring for a group of clients. The nurse should identify that which of the following tasks is within the nurse's cope of practice? A. Changing the form of a medication for a client who is unable to swallow B. Inserting an endotracheal tube for a client experiencing respiratory distress C. Inserting a subclavian central venous access device D. Inserting a Salem sump tube for gastric decompression
D. Inserting a Salem sump tube for gastric decompression It is within the scope of nursing practice to insert and maintain an NG tube for removing air and fluid from the stomach. A Salem sump tube is preferable for this purpose. It has two lumina, one for removing stomach contents and the other for providing an air vent. The nurse should contact the provider to change any part of a medication prescription. Changing the form of a medication is beyond the scope of nursing practice. Clinicians who have received specialized training in endotracheal intubation can insert endotracheal tubes. This task is beyond the scope of nursing practice. Providers and advance practice nurses who have received specific training and/or certification can insert subclavian central venous access devices. This task is beyond the scope of nursing practice. Nurses can insert peripherally inserted central catheters (PICCs) with specialized training.
A nurse is reviewing guidelines for documentation in an electronic medical record with a newly licensed nurse. Which of the following information should the nurse include? A. It is important to include personal opinions when documenting assessments. B. Wait until the end of the shift to document an error. C. It is acceptable to document for another nurse in urgent situations. D. Log out of the computer terminal after completing documentation.
D. Log out of the computer terminal after completing documentation. It is important for the nurse to maintain the security of clients' medical records. Without logging out, others could view or access clients' confidential health information.
A nurse is planning to obtain a pulse oximetry reading for a client who has peripheral vascular disease. Which of the following actions should the nurse plan to take? A. Place the client in the supine position. B. Elevate the client's extremities. C. Tell the client to expect a mild vibration when the probe generates the reading. D. Place the probe on the client's earlobe.
D. Place the probe on the client's earlobe. The nurse should identify that a pulse oximetry reading might be difficult to obtain in clients who have impaired peripheral circulation. Therefore, the nurse should place the probe on the client's earlobe or forehead.
