VATI funds NURSING MISC Proctored Exam
2020|2021
A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam
oral solution 5 mg/1 mL. How many mL should the nurse administer with
...
VATI funds NURSING MISC Proctored Exam
2020|2021
A nurse is preparing to administer diazepam 2 mg twice daily via NG tube. Available is diazepam
oral solution 5 mg/1 mL. How many mL should the nurse administer with each dose? (Use a leading
zero if itapplies. Do not use a trailing zero. Round the answer to the nearest tenth.)
0.4
A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected
clients who have chronic pain. The nurse should identify that the use of therapeutic touch is
contraindicated for which ofthe following clients?
A client who has chronic back pain and a history of being physically abused
Therapeutic touch consists of using the nurse's hands to harmonize energy fields and to
facilitate relief of painor anxiety, such as for a client who has chronic back pain. The nurse can
touch the client with their palms or move the palms near, but not touching the client's body.
Prior physical maltreatment and some mental health disorders are contraindications for
therapeutic touch, because touch or near touch could cause severe anxiety.
A nurse in a rehabilitation unit is assessing a group of clients who have traumatic brain injuries.
The nurseshould identify that which of the following clients requires a priority referral?
A client who coughs after drinking liquids
The greatest risk to this client is injury from aspiration. Therefore, this is the client the nurse
should address first. The priority referral the nurse should make is to a speech-language
pathologist because a client who coughs after drinking liquids is at risk for aspiration.
Manifestations of dysphagia include changes in voice tone,coughing, delayed swallowing,
pocketing of food, and occasional silent aspiration, which can occur if a client isexperiencing a
decrease in sensation.
A nurse is assisting a client to move up in bed. Which of the following actions should the nurse take?
Raise the height of the bed to the level of the nurse's elbows.
A nurse is caring for a client who is at risk for pressure ulcer formation due to immobility. The
nurse shouldplace the client in which of the following positions to reduce pressure on the client's
bony prominences?
30° lateral
The 30° lateral position, along with positioning devices, can prevent pressure directly over the
client's most vulnerable bony prominences. This position can, however, cause pressure on the
shoulder, ankle, anterior iliacspine, and trochanter. Therefore, the nurse should ensure the
client's head is midline and supported, rotation ofthe spine is avoided, and position changes are
implemented every 1 to 2 hr
A nurse is preparing to administer vancomycin 500 mg by intermittent IV infusion every 6 hr.
Available is vancomycin 500 mg in 0.9% sodium chloride 100 mL to infuse over 2 hr. The nurse
should set the IV pump todeliver how many mL/hr? (Round the answer to the nearest whole
number. Use a leading zero if applicable. Do not use a trailing zero.)
50
A nurse is admitting a client who is to undergo a surgical procedure. Under the Patient SelfDeterminationAct (PSDA), which of the following actions is the nurse's responsibility regarding
the client's advance directives?
Ask the client whether he has created advance directives.
A nurse is assessing a client who has hypokalemia. Which of the following manifestations should
the nurseexpect?
Decreased bowel sounds
Decreased bowel sounds are an indication of hypokalemia because of decreased excitability of
cells, resultingin less responsiveness to normal stimuli in nerves and muscles.
A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical
ventilation.Which of the following interventions should the nurse include to reduce the client's
risk for ventilator- associated pneumonia?
Swab the client's mouth with chlorhexidine solution.
A nurse is providing teaching to a client following a thoracentesis. Which of the following actions
should thenurse take?
Position the client on her unaffected side.
The nurse should position the client on the unaffected side to help facilitate expansion of the
affected lung
A nurse is completing a neurological assessment of an older adult client and notes that the client has
becomeincreasingly confused and agitated in the last 48 hr. Which of the following conditions is the
priority assessment by the nurse?
Infection
A nurse is assessing a client who is receiving intermittent catheter irrigation following a
transurethral resection of the prostate (TURP). Which of the following manifestations is the
priority for the nurse to reportto the provider?
Increase in bladder spasms
A nurse is providing discharge teaching to a client who has heart failure and a new prescription for
furosemide. Which of the following foods should the nurse recommend to the client as the best
source ofpotassium?
1 cup cantaloupe
A nurse is preparing to administer an opioid medication to a client who is experiencing pain.
Which of thefollowing actions should the nurse take?
Ask a second nurse to witness the discarding of unused opioid medication.
The nurse should ask a second nurse to witness the discarding of unused opioid medication
and sign thedesignated form.
A nurse is providing discharge teaching to a client who is prescribed home oxygen therapy using
a compressed oxygen system. Which of the following statements by the client indicates to the
nurse that theteaching has been effective?
"I will store oxygen tanks in an upright position."
This statement by the client indicates an understanding of the teaching. The nurse should
instruct the client tostore oxygen tanks in an upright position in a holder to prevent damage to
the tank and injury to the client andthe client's family.
A school nurse is teaching a group of parents about measures to prevent firearm injuries in the
home. Whichof the following instructions should the nurse include in the teaching?
"Keep ammunition and guns in separate, locked locations."
A nurse is performing postmortem care for an older adult client who has just died. Which of the
followingactions should the nurse take?
Identify the client using two identifiers.
The nurse should identify the deceased client using two identifiers, such as name and birth date,
or name andaccount number, and then compare the identifiers to the information in the client's
medical records.
A nurse is caring for a client who had a stroke and is immobile. Which of the following actions
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