(Test Bank) Everything on VATI 2022-2023/COMPLETED VATI Greenlight STUDY SET 2022-23/Test Bank with Complete solutions

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Test Bank for Everything on VATI 2022-2023/COMPLETED VATI Greenlight STUDY SET 2022-23/Test Bank with Complete solutions, The downloadable file consists of 153 pages, and the total size of the file is 0.82 MB. Purchase now only for highly discounted price.

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Everything on VATI 2022 -2023 /COMPLETED VATI Greenlight STUDY SET 2022 -23/Test Bank with Comple te solutions A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? The infusion pump for administe ring contimuous feeding is turned off. A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the following findings should the nurse expect? Hypotension A nurse is providing dietary teaching to a client who has an increased cholesterol level. Which of the following foods should the nurse recommend? Egg whites A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following action s should the nurse plan to take? Use a designated stethoscope when caring for the toddler. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse? 1cm of water present in the water seal A nurse is reviewing the medical history of a client who is taking garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement? The client takes aspirin daily. A nurs e is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? Series of four hepatitis vaccines is recommended to prevent viral hepatitis. A nurse is reviewing the history and p hysical of a client who has right ventricular heart failure. Which of the following is an expected finding? Elevated pulmonary artery pressure A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client h as two school -age children and a limited support system. Which of the following is the priority nursing action? Inform the client of available community resources. A nurse is providing postoperative teaching to a client who has a newly -inserted pacemaker. Which of the following statements by the client indicates that the teaching has been effective? "I will use my cell phone on the ear opposite of my pacemaker." A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Whi ch of the following findings indicates the client is experiencing an adverse effect of the medication? Decreased reflexes A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? Wear an N95 respirator. A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.) The nurse should pad the bony prominences. The nurse should remove the restraints every 2 hr. The provider's prescription should include the A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include? Educating the client how to cover nose and mouth with tissues when coughing A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? Schedule routine care tasks duri ng hours when the client is awake. A nurse is preparing a client for surgery and has just administered the preoperative injection. Which of the following actions should the nurse take? Review deep breathing and coughing exercises. A nurse suspects another nurse is chemically impaired during their shift. Which of the following is an appropriate action for the nurse to take? Report to the nurse manager. A nurse in the recovery room is assessing a client who has a new chest tube. The n urse finds that the water seal is no longer tidaling. The nurse should identify the finding as resulting from which of the following? The tubing may be kinked. A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Whe n admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN? Measure the amount of gastric drainage every 2 hr. A nurse is assessing an adult male client who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories? Healthy weight A nurse is assessing a client who has a long arm cast. For which of the following findings should the nurse monitor when assessing for acute compartment syndrome? Change in mental status A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first ? (Click on the "Exhibit" button for additiona l information about the client. There are three tabs that contain separate categories of data.) Administer pain medication to the client. A community health nurse is performing a vision screening on a 4 -month -old infant. When shining a light source into the infant's visual field, which of the following is an expected finding? The infant closes their eyes. A nurse is planning discharge teaching for a client who is scheduled to receive intravenous infusions at home. Which of the following instructions shoul d the nurse plan to include? Place the infusion pump cord against the baseboards. A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following actions by the assistive personnel requires the nurse to int ervene? Offers oral fluids to the client A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? Generalized edema A nurse is caring for a client who is in labor and receiving electronic fetal mon itoring. The nurse is reviewing the monitor tracing and notes early decelerations. Which of the following should the nurse expect? Head compression nurse in a pediatric unit is caring for a group of clients. For which of the following diseases should the nurse implement droplet precautions? Pertussis A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should assess for which of the following potential contraindications? Shellfish allergy A nurse at the family planning clinic tr iages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic? A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding A nurse is caring for a c lient who has a hearing impairment. When speaking to the client, the nurse should incorporate which of the following communication methods? Rephrase sentences the client does not understand. A nurse in a mental health facility is interviewing a newly admitted client. Which of the following actions should the nurse take when conducting the interview? Lean in slightly when speaking to the client. A nurse is caring for a group of clients. Which o f the following clients should the nurse assign to an assistive personnel? A client who had a stroke 2 days ago and needs help toileting A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted infections in the community. The purpose of which of the following is to generate new ideas to address the public health concern? A brainstorming session with nurses A nurse is providing teaching about preventing mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following instructions should the nurse include? "Try to have your baby empty your breasts with each feeding." A nurse is preparing to insert an indwelling urinary catheter for a female client. 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.) Apply sterile gloves and place cleansing balls in antiseptic solution. Attach prefilled syringe to indwelling catheter inflation hu b. Cleanse the meatus with the dominant hand in a downward motion. Lubricate the catheter and place fenestrated drape over perineum. Insert the catheter until a flow of urine begins. A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing episodes of nausea and vomiting. Which of the following instructions should the nurse include? Eat a dry carbohydrate before getting out of bed. A nurse is caring for a client who is nulliparous and in the first stage of labor. The last in ternal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse? Check the FHR. A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take? Report the incident to Adult Protect ive Services. A nurse is caring for a client who is postpartum and has a new prescription for methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When reviewing the client's medical history, the nurse should recognize which of the following diagnoses as a contraindication to the administration of methylergonovine? Hypertension A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the cli ent states, "My stoma will drain liquid fluid continuously." At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the nurse a list of client reports. Which of the following client reports should the nurse assess first? Indigestion A nurse is caring for a client who has constricted pupils, delayed reflexes, and decreased blood pressure. The nurse should identify that these findings are potential manifestations of which of the following? Opioid intoxication A nurse is review ing the medical record of a client who has new prescription for gentamicin. The nurse should identify that concurrent use with which of the following current medications can increase the client's risk for ototoxicity? Furosemide A nurse is caring for a cli ent who is at high risk for developing diabetes insipidus (DI) following a severe head injury. Which assessment finding indicates to the nurse that the client is developing DI? Urine output of 250 mL/hr A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis? Sputum culture A home health nurse is teaching a guardian about administering tube feedings to their 3 -month -old infant. Which of the following information should the nurse include in the teaching? Allow the infant to suck on a pacifier during feedings. A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open." The nurse notes dehiscence of the incision. Which of the following actions should the nurse take? Place the client in a low -Fowler's position. A nurse is assessing a cli ent's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take? Dim the lights in the room prior to the examination. A nurse is providing discharge teaching to a client who is postpartum and plans to breastfeed. Which of the following should the nurse recommend the client increase in their diet during lactation? Iron A nurse is planning teaching for a client who is at 10 weeks of gestation and has a history of urinary tract infections (UTIS). Which of the followin g information should the nurse plan to include in the teaching about UTI prevention? Empty the bladder before and after intercourse. A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions should the nurse take? Monito r for abdominal ascites. A nurse is providing teaching to an adolescent client who has cystic fibrosis and has a prescription for pancrelipase. Which of the following should the nurse include in the teaching? Take with meals. A nurse is caring for a clie nt who is receiving continuous enteral feedings and reports diarrhea. Which of the following actions should the nurse take? Discard opened cans of formula after 24 hr. A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions? Ototoxicity A nurse is caring for a client who reports the use of chondroitin and glucosamine. The health benefit of this supplement combination is to do which of the following? Improve joint functioning. A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching? Hospice care encourages the family to coordinate health care services. A client has just returned to the nursing unit following cardiac catheterization. In the immediate postprocedure period, which of the following is the priority nursing action? Monitoring the insertion site for infection A nurse is caring for a client who has a newly i mplanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take? Require the cient wear a dosimeter badge. A community health nurse is teaching a group of restaurant workers about hepatitis A. Which of the following statements should the nurse make? "Hepatitis A can be spread by fecal -oral contact." A nurse in a mental health clinic is observing clients the day room. The nurse sits down to talk with an adolescent client who was admitted with clinical depression. After a few minutes of conversation, the adolescent asks the nurse, "Why did you choose to talk to me out of this room full of kids?" Which of the follo wing responses by the nurse is therapeutic? "You're curious why I am interested in you and not the others?" A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laborator y tests to determine effective long -term management of blood glucose levels? HBA1C The following assessment findings should indicate to the nurse that the NG tube might not be functioning properly? A nurse is caring for a client who is postoperative follow ing a bowel surgery and has an NG tube connected to low intermittent suction. Which of Abdominal rigidity A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the high est priority for the client to report to the provider? Fever A nurse is discussing the Z -track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the te chnique? "This technique decreases the risk of subcutaneous infiltration." A nurse is caring for a client who has opioid use disorder and is experiencing withdrawal. Which of following findings should the nurse expect? Hyperreflexia A nurse is giving chang e-of-shift report about a client who is 36 -hr postoperative to another nurse. Which of the following should the nurse include? Relieved by position change A nurse is caring for a client who has been taking propranolol. Which of the following findings indic ates a need to withhold the medication? Pulse 54/min A nurse is reviewing the medical records of four clients. Which of the following prescriptions represents correct documentation? Sucralfate 1 g PO 1 hr ac A nurse is evaluating the allergy profile of a c lient who has Graves' disease and is to undergo a thyroid scan. The nurse should identify which of the following allergies as a contraindication for the client to undergo a thyroid scan? lodine A home health nurse is assessing a client who reports a headac he and appears confused and drowsy. The client has a kerosene space heater in use. Which of the following actions should the nurse take first? Open the client's windows. A nurse is teaching a newly licensed nurse about informed consent. Which of the follow ing statements should the nurse include in the teaching? (Select all that apply.) Witnessing the signing of the informed consent form, the nurse is indicating that the client voluntarily gave client who signs an informed consent form should understand the treatment plan." "A client who signs an informed consent form should be competent." "The nurse should disclose the purpose of the treatment before the client signs the consent form." A nurse is providing teaching to the guardian of a school -age child who h as a new prescription for ferrous sulfate capsules PO. Which of the following instructions should the nurse include in the teaching? Administer the medication with a glass of orange juice. A nurse is providing grief counseling for the parents of a school -age child whose sibling recently died. Which of the following statements should the nurse make? "Bring the child to the funeral service before visitors arrive." A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings Indicates fluid overload? Bounding pulses A nurse is caring for a client who is taking levothyroxine. Whi ch of the following findings should indicate to the nurse that the medication is effective? Weight loss A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? Place the newborn 45 cm (18 in) from the light source. A nurse is preparing to witness a client's signature on an informed consent for a total knee arthroplasty. Which of the following client statements indicates the nurse should contact the surge on? "I am thankful there are no serious complications from this type of surgery." A nurse is caring for a 7 -year -old child who has severe dehydration. Which of the following findings should the nurse expect? Blood pressure 94/68 mm Hg A charge nurse is cre ating assignments for the next shift for several nurses and one of the nurses is pregnant. Which of the following clients should the charge nurse assign to a nurse who is not pregnant? An 80 -year -old client who has alcoholic pancreatitis and is being treat ed for impetigo A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder (OCD). Which of the following is appropriate for the nurse to include in the plan of care? Teach the client to meditate about obsessive thoughts. A nurse is caring for client who has schizophrenia. Which of the following findings is the nurse's priority? The client reports hearing voices. A nurse is preparing to administer eye drops to a client. Which of the following nursi ng actions is appropriate? Use aseptic technique and drop the medication into the conjunctival sac. A nurse is caring for a client who has schizophrenia. The nurse should expect the client to exhibit which of the following manifestations? (Select all that apply.) Repeats the words of others when speaking Speaks in word salad Has a blunt affect Experiences delusions A nurse is assessing a client who has a fentanyl patch in place for chronic pain. Which of the following findings should the nurse report to the provider? No bowel movement for 3 days A charge nurse overhears two assistive personnel (AP) in the unit lobby discussing the HIV status of a client. Which of the following responses is the priority for the nurse to make? "Please stop this discussion." A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first? Determine the client's pain level. A nurse is providing dietary teaching for a cl ient who has a history of nephrolithiasis. Which of the following is appropriate to include in the teaching? Avoid foods that have high levels of oxalates. A nurse on a labor and delivery unit is assessing four newly admitted clients. Which of the followin g clients should the nurse see first? A client who is at 36 weeks of gestation and reports decreased fetal movement for 2 days A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care? Maintain the head at a midline position. A nurse is c aring for a client who reports chest pain. Which of the following laboratory findings indicates myocardial damage? Troponin I 1.8 ng/mL A nurse is caring for a client who has a prescription for vancomycin 1 g IV every 12 hr. The client is scheduled to have the morning dose at 0700. The nurse should schedule the trough level to be drawn at which of the following times? 0900 A client who has a diagnosis of com acenta is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the following actions should the nurse take? Prepare the client for a cesarean section. A nurse in a substance use unit spends an equal amount of time with each of his assigned clients, even though some of the clie nts have committed serious crimes. Which of the following ethical principles is the nurse demonstrating? Justice A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing ? Hyperemesis A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of the following medications should the nurse expect the provider to prescribe? Sertraline A nurse is performing change -of-shift assessments for four clients. Which of the following findings should the nurse report to the provider first? A client who has gastroenteritis and is lethargic and confused A nurse is planning care for a client who has a gambling disorder. Which of following instructions should the nurse provide to the client? Participate in a 12 -step program . A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the following is the priority action? Notify the faci lity A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hr and develops a hemolytic reaction. Which of the following actions should the nurse perform? Infuse 0.9% sodium chloride V. A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need for which of the following equipment? Pulse oximeter A nurse is teaching a client who has a new prescription for digoxin. Which of the following statements should the nurse include in the teaching ? "Notify your provider if you experience muscle weakness." A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding? Swollen lips A nurse is teaching the guardian of an infant who has developmental dysplasia of the hip about a Pavlik harness. Which of the following instructions should the nurse include? Gently massage the skin under the straps once per day. A nurse in an inpatient me ntal health facility is caring for a client who has major depressive disorder and refuses to take her medication. Which of the following actions should the nurse take first? Identify the reason for the client's refusal. A nurse is performing an admission a ssessment for a client who is to undergo a colonoscopy. The client informs the nurse that he took his prescribed medications before coming to the clinic. Which of the following medications is the priority to report to the provider? Clopidogrel A nurse is a ssessing a client prior to performing a blood draw. The nurse should identify that an allergy to which of the following foods can indicate that the client has an allergy to latex? Avocados A nurse from the State Health Department is instructing a group o f nurses regarding reportable infections. Which of the following infections should the nurse report to the Centers for Disease Control and Prevention? Lyme disease A nurse is caring for a client who has a prescription for atorvastatin. Which of the followi ng client conditions is a contraindication this medication? Нерatitis C A nurse is preparing to administer an IV bolus of albumin 5% to a client who is receiving a continuous IV infusion. After confirming compatibility, which of the following actions shoul d the nurse take? Occlude the IV tubing above the injection port. A nurse is planning care for a client who is postoperative following creation of an arteriovenous fistula in the left arm. Which of the following actions should the nurse include in the plan ? Compare blood pressure in both arms every 2 hr. A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report? Client found lying on the floo r near the bedside table. A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate? "Do you have a plan to end your life?" A char ge nurse is teaching a group of unit nurses about the policy for clients who have a history of methicillin -resistant Staphylococcus aureus (MRSA). Which of the following information should the nurse include? A client who has a history of MRSA can still tra nsmit the infection, A nurse is caring for an adolescent who is receiving treatment for heart failure. Based on the client's chart findings, which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional informa tion about the client. There are three tabs that contain separate categories of data.) Withhold digoxin. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is asymmetric, with variegated coloring. A nurse is assessing a client who is gravida 2, para 1. The client is at 41 weeks of gestation and is receiving oxytocin for the augmentation of labor. The nurse should decrease the infusion rate for which of the following findings? Consistent contractions last 80 seconds. A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective? Pedal pulses 2+ A nurse is caring for a client who experienced a st roke and has dysphagia. Which of the following findings should indicate to the nurse the client is at risk for aspiration? The client pockets food on one side of his mouth. A nurse is teaching the parent of a school -age child who has scabies about the appl ication of permethrin 5% cream. The nurse should include which of the following as a potential adverse effect of the medication? Burning A nurse is creating a plan care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? Monitor the client for 1 hr after meals. A nurse is performing triage following a natural disaster. Which of the following clients should the nurse identify as the highest priority to receive care? A dient who has a traumatic arm amputation A nurse performing a skin assessment for a client who is on bedrest. Which of the following actions should the nurse take prevent a pressure injury? Encourage client fluid intake of 2,500 ml daily. A nurse is teaching a group of farmworkers who work with pesticide about minimizing exposure. Which of the following information should the nurse include in the teaching? Change clothes after working in the field. A nurse is observing bonding between a client and her newborn. Which of the following ac tions by the client requires the nurse to intervene? Viewing the newborn's actions to be uncooperative A nurse is caring for a client following insertion of a subclavian prescription to initiate an IV infusion of Ringer's lactate at 150 ml per hr. Prior to starting the infusion, which of the following actions should the nontunneled percutaneous central venous catheter (CVC). The provider writes a nurse take? Review the chest x -ray report. A nurse is admitting a client who has antisocial personality disorder . Which of the following client behaviors should the nurse identify as consistent with this disorder? Uses others for personal gain 2hrs post -op following an ileal conduit procedure bladder cancer Dusky -colored stoma Administering an INJ to a client even after the client states, "I don't want that injection. The last time I got that I was sore for a week." Battery Admitting a client to the medical -surgical unit. Which of the following actions should the nurse first take? Observe the client's level of mob ility Adolescent client who has no previous history of a seizure disorder and is admitted after having a 3 -min tonic -clonic seizure 2 wks after sustaining a mild concussion. EEG Explain that the client may not have coffee prior to the EEG Adolescent who ha s cystic fibrosis and has a prescription for pancrelipase Take w/ meals After evaluating the morning lab results on several clients, the provider writes prescriptions for 4 clients assigned to the nurses care? Infuse 10 meQ/l potassium chloride IV over 1 h r to a client who has potassium of 3.2 After making morning round, the charge nurse on a surgical unit delegates the follow tasks to the AP. Set up a room for an expected postoperative admission AP reports to the nurse that another ap has spent the entire morning on the phone and has not completed the morning assignment Redirect the AP to discuss the issue with the other AP Assessing client who systemic lupus erythematous SLE which of the followin g is an expected findings Dry, raised facial rash At the start of an evening shift on a cardiac unit, a LPN brings the nurse a list of client reports Indigestion Benefit from a three -way indwelling catheter Prone to development of blood clots un the urine Caring for a client who has a new prescription for chlorpromazine by IM injection Check orthostatic BP 1 hr after admin Caring for a client who was involved in a motor -vehicle crash. The client reports shortness of breath and chest pain and asks the nurse "Am I dying?" Admin pain meds Charge nurse creating assignments for next shift for several nurses and one of the nurses is pregnant - which pt the nurse should NOT be assigned to? 60 yr old who is recovering from shingles Charge nurse on pediatric unit is making assignments for a float nurse from the medical unit. Pt to see first? 10 yr old who has pneumonia & is receiving respiratory txs Child who has pediculosis capitis store non-washable items in plastic bags for 14 days Child who is unresponsive has ICP Pad the side of the bed Client who has a left femur fracture and is skeletal traction. The clients reports pain due to muscle spasms in affected leg Realign the extremity in traction Client who has given birth to a stillborn Acknowledging the reality of the newborn's death Client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea Admin an antiemetic (Aprepitant for nausea) Client who is 8hr postoperative following a right -modified radical mastectomy - which findings to report to provider? (SATA) Coughing Frothy, pink secretions Client who is receiving a controlled epidural analgesia infusion Covering the insertion site with a transparent dressing Client who reports the use of chondroitin and glucosamine Improve joint fun ctioning Community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house Review the effects of secondhand smoke w/ family members A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic Determine the client living situation A community health nurse is planning to make home visits to several clients who all live within a few miles radi us of the office - Who to see first? An infant who has failure -to-thrive and was discharged from a facility yesterday to a foster home on daily weights Creating and activity plan for a home bound older adult client. In the planning, the nurse considers the physiologic changes that may affect pulmonary function r/t the normal aging process Decreased blood oxygenation Delegates the following tasks to the AP bathe four clients, distribute fresh water, obtain morning vital signs Set a clear time frame for the c ompletion of each task DI w/ severe head injury Urine output 250 Diagnosis of antisocial personality disorder Poor impulse control Diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36wks gestation w/ contractions 5 min in frequency and 1 min in duration Prepare the client for c -section Dietary intervention for a client who is immobile due to pelvic and femur fractures Provide a high - protein diet Difficulty falling asleep at night Eat a bedtime snack (containing carbohydrat es??) Disaster triage following a natural disaster Amputation Discharge teaching about disease prevention to a client who has active Tb Educating the client how to cover nose and mouth with tissues when coughing Discussing a living will with a client It co mmunicates my wishes for end of life care Discussing care w/ newly licensed nurse for a client who practices orthodox Judaism - which food not given? Roast beef and ice cream Education about ECT major depressive disorder General anesthetic admin prior ECT treatments(This treatment are for pts who aren't responding to their pharmaceutical meds) Education to the mother of a toddler who has pertussis Pertussis booster An emergency department nurse triages a group of school children injured in a school bus cras h A child who reports diplopia and nausea and was unconscious at the scene but is now awake Experiencing acute mania ... Provide high -calorie nutritional supplements (provide pt with portable nutritious food because pt may not be able to sit down) Gravida 2, para 1. The client is at 41 wks gestation and is receiving oxytocin for the augmentation of labor Contractions occur every 90 sec Haloperidol for the tx of schizophrenia Screen the client for Tardive Dyskinesia (inform pt to lower doses to decre ase the chances of TD) Health nurse is performing a vision screening on a 4 -month -old infant. When shining a light source into the infant's visual field - rx? Closes eyes Hearing impairment - incorporate which communication methods? Rephrase sentences the client doesn't understand Home health nurse is admitting a client who is prescribed peritoneal dialysis Clarify the clients actual and perceived health needs A home health nurse is conducting an initial home visit for a client who has terminal breast cance r. The client who has 2 minor children and a limited support system Ask the client about her understanding of the diagnosis A home -health nurse is providing teaching about self -administration of insulin to client who is newly diagnosed w/ diabetes mellitus I can use the same area as long as I rotate injection sites Home health nurse is reviewing treatment goals w/ a client who has diabetes mellitus evaluate lab tests to determine effective long -term management of blood glucose levels HbA1C Hyperthyroidism - which of the following rooms is appropriate for the nurse to assign this client? Cool room (reduced room temp) If something happens to me from which I cannot recover, I don't want to go on a ventilator: You're concerned that something may go wrong? Ileal conduit due to treatment for bladder cancer Cleanse w/ moisturizing soap Immediate postoperative period following thorac surgery, a nurse medicates a client for pain on a schedule Reduces the RR Infection control nurse is reviewing care procedures for four clients A client who has varicella zoster is placed in a negative pressure room In-home assessment for an older adult client who is at risk for falls. Which of the following assessment findings should the nurse identify as a potential hazard? A comp. ch air wheels In patient psychiatric unit is setting short -term goals for an adolescent who was admitted for tx of anorexia nervosa The client will develop personalized meal plan Involuntarily admitted to psychiatric unit following a failed suicide attempt - experimental tx Witness consent before medication administration Lab data on client who has dehydration Elevated BUN Lab values on a client who has taken an overdose of acetaminophen - organ damage ALT Mastitis of left breast - does this mean that i must stop nursing my baby? No, you can continue to nurse from both your breasts medical unit received change -of-shift report ... 68 yr old Morning lab values to several clients ... Client who is prescribed di goxin and furosemide Pt w/ Neutropenia (MS pg. 543) Remove fresh flowers from a client's room Newborn nursery is performing assessments on four neonates that are all less than 24 hr old - which pt is priority? Pinna below the outer canthus of the eye (The eye should be even with the upper tip of the pinna of the newborn's ear; MN p. 158) Pt is Nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement w/ 5cm of dilation. At the end of last contraction, the nu rse observes a large gush of fluid coming out of clients perineal area. What should nurse do first? Check FHR!! A nurse at a public health clinic is caring for a group of clients. Which of the following should the nurse identify as a reportable dx to the C DC? Hepatitis A A nurse at the family planning clinic triages several clients over the phone - (PRIORITY)? Sharp pain in RIGHT shoulder A nurse delegates tasks to a LPN and an AP. When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube - which of the following tasks is most appropriate to delegate to the LPN? Insert an indwelling catheter if the client has not voided in 3 hr A nurse educator is discussing modes of transmission w/ nursing students. Which of the fo llowing should the nurse educator include as an example of vector -borne transmission? West Nile virus from mosquito bite A nurse in a mental health clinic is observing clients in the day room. The nurse sits down to talk w/ an adolescent client who was adm itted w/ clinical depression. After a few minutes of convo, the adolescent ask the nurse "why did you choose to talk to me out of this room full of kids?" You're curious why I am interested in you and not the others? A nurse in a mental health clinic is re viewing the hx and physical for a 17 -yr old client who has a new dx of social phobia: Client reports minimal alteration in performance at a part -time job Nurse in an emergency department is assessing a client who has a nasal fracture. Clear fluid drainage from the nares A nurse in a pedi unit is caring for a group of clients. Which of the following diseases should the nurse implement droplet precautions? Pertussis A nurse in a provider's office is caring for a client who has Parkinson's Disease and has been taking levodopa for the past 5 wks. The client reports a new onset of muscle twitching - best response? This is a manifestation of drug toxicity & may require a dosage reduction A nurse in the emergency department is caring for a client following a motor vehicle crash - PRIORITY? Stabilize the cervical spine A nurse in the emergency department is caring for a client who has abdominal pain. Which of the following actions by the nur se demonstrates VERACITY? A nurse explains the potential risks of tx. (Veracity = truth/not withhold all info; Fidelity = keeping promises) A nurse in the emergency department is providing discharge teaching to a client who has a sprained ankle. For the f irst 24hr following sx, the nurse should instruct the client to do which of the following? Intermittently place ice on the ankle (30 mins - 1 hr??) A nurse in the PACU is caring for four post -op clients. The nurse realizes that coughing poses a risk to which of the following clients? Thyroidectomy (Coughing can cause incision to reopen & bleeding can occur) A nurse is admitting a client who has chronic gout - What med should the nurse admin? Allopurinol A nurse is admitting an infant who has bacterial me ningitis. Nursing intervention? Minimize environmental stimuli A nurse is admitting an unidentified female who was brought to the emergency department: 3 months A nurse is analyzing cardiac rhythms of four telemetry clients in the coronary care unit: C loo ks normal but lots of artifact or Fibs in between QRS's A nurse is assessing a client 1 wk after a successful bone marrow transplant. The client reports peeling of skin on her hands and feet. The nurse should recognize this desquamation as an indication of which of the following complications? Graft vs host disease A nurse is assessing a client who has an IV infusing per gravity at 125ml/hr Blood is backing up in the IV tubing A nurse is assessing a client who is 2 hrs post -op following insertion of a chest tube connected to chest drainage system as depicted in the diagram above: Fluctuation of the fluid level chamber b (middle) A nurse is assessing a client who is post -op following abdominal sx. States "I feel like my incision ripped open." Place client in Low-Fowler's position A nurse is assessing a client w/ schizophrenia - what is a manifestation? Auditory hallucinations A nurse is caring for a client following insertion of a subclavian non -tunneled percutaneous central venous catheter - What should nurse do? Review the chest x -ray A nurse is caring for a client who has a partial laryngectomy and is receiving continuous enteral feedings at 65ml.hr through a gastrostomy tube (intervene??) The client is lying in a supine position A nurse is caring for a client who has newly implanted sealed internal radiation device to treat cervical cancer. Keep a 3 ft distance from the radiation implant A nurse is caring for a client who has a new prescription for lithium carbonate. PRIOR TO ADMI NISTERING THE FIRST DOSE, WHICH OF THE following lab values should the nurse evaluate? Sodium A nurse is caring for a client who has a typical depression and is taking phenelzine - What can you eat? Low-fat yogurt A nurse is caring for a client who has cir rhosis of the liver: Monitor for abdominal ascites Nurse is caring for a client who has end stage liver disease. The daughter of the clients ask about her father's DNR request. Tell me your feelings bout your father's prognosis. A nurse is caring for a c lient who has heart failure and has started taking a loop diuretic: Decreased reflexes A nurse is caring for a client who has just returned to the unit following a bronchoscopy: Offer oral fluids to the client A nurse is caring for a client who is manic. W hich of the following activities is appropriate for the nurse to suggest? Taking walks (physical activity) A nurse is caring for a client who is postoperative and at risk for development of DVT - Risk factor? Prolonged bed rest A nurse is caring for a clie nt who is receiving enteral nutrition. What lab level should be reported? Serum sodium of 128 A nurse is caring for a client who is receiving gentamicin. Which of the following findings indicates the client is developing toxicity? Tinnitus P-pee (furosemid e) A-abx & aspirin C-cancer (tamoxifen) T-tinnitus A nurse is caring for a client who is receiving IV antibiotics and tests positive for C. diff - PRIORITY? Place client on contact precautions A nurse is caring for a client who will be receiving a transfusion of platelets - Effectiveness? Decrease in bleeding from puncture sites A nurse is caring for a client with fractured ribs, has developed thrombophlebitis, and is being treated with a hepari n drip. The client develops hematuria and has an aPTT of 100 seconds - What nurse do next?? Turn off heparin drip A nurse is caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? (SATA) -Transfer a client from bed to chair w/ mechanical lift -Provide postmortem care on a client who experienced cardiac arrest A nurse is caring for a mother who was prescribed methadone during pregnancy (MN p. 183): -Tachypnea -Irritability -Tremors or -Increased sei zures, sleep pattern disturbance, higher birth wt A nurse is caring for an infant who is being treated for dehydration - indication for further education? -Flat anterior fontanel (Reason: Fontanels should be soft & flat; No tears = dehydration) A nurse is caring for a post -op client. Which of the following interventions will reduce the risk of DVT? Apply venous plexus foot pumps A nurse is caring for a preschool -age child who has a short -leg, plaster cast applied 1 hr ago. Support the affected leg on a pil low A nurse is discussing the z -track method to admin hydroxyzine hydrochloride w/ a newly licensed nurse - Understanding of teaching?