MEDSURG VATI ASSESSMENT 90 Q'S With Accurate answers, Graded A+

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A nurse is assisting with the care of four clients. Which of the following clients is the priority for the nurse to see -A client who has chest tubes and an oxygen Sat of 90% - aclient who has pe... ripheral edema and urinary output of 130 over 4hrs - A client who has a permanent pacemaker with heart rate of 76/min -a client who has pericarditis and temp. 38 c 100.4 - ✔✔- A client who has chest tubes and an oxygen Sat of 90% Using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding is the client's oxygen saturation level, which is below the expected reference range of 95% to 100%. Therefore, the nurse should attend to this client first. A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3. Which of the following findings should the nurse expect? - Vacalizes sound -Blinks eyes when asked -Follows motor commands -Nonresponsive Commands - ✔✔Nonresponsive Commands A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose state. The GCS is a standardized tool that allows for the evaluation of a client's level of consciousness. The test is divided into three sections that evaluate eye opening, motor response, and verbal response. The GCS ranges from a high score of 15 (fully alert) to a low score of 3 (fully comatose). A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a closed chest drainage system connected to low suction. For which of the following findings should the nurse notify the charge nurse - Fluctation of the water level in the water seal chamber -constant bubling in the suction control chamber - periodic bubbling in the water seal chamber - Persistent bubbling in the water seal chamber - ✔✔- Persistent bubbling in the water seal chamber Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the drainage system. The nurse should notify the charge nurse of this finding. A nurse is reinforcing teaching with a male client who has right sided hemiparesis about preforming ADL's. Which of the following instructions should the nurse include in the teaching -Comb your hair with the unaffected arm -Dress your unaffected side first choose clothing with buttons -shave with your affected side - ✔✔Comb your hair with the unaffected arm The nurse should instruct the client to brush their hair with the unaffected arm to reduce frustration and increase independence and self-esteem. A nurse is collecting data from a client and auscultates intermittent high-pitched sounds during inspiration over the lower base of the lungs. The nurse should identify this finding as which of the following lungs sounds - Fine crackles -stridor -rhonchi -friction - ✔✔- Fine crackles Fine crackles are auscultated in the base of the lungs as air moves through airway secretions. Fine crackles are intermittent, high-pitched sounds heard more often during inspiration. A nurse is collecting data from a client who has coronary artery disease. Which of the following manifestations should the nurse identify as an indication that the client has angina ( SatA) - Chest Discomfort Radiated - Pain lasting less that 15mins - Pain that is relieved with rest - ✔✔- Chest Discomfort Radiated - Pain lasting less that 15mins - Pain that is relieved with res A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first? - A client who has diabetes mellitus with diaphoretic - ✔✔A client who has diabetes mellitus with diaphoretic When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to attend to a client who has diabetes mellitus and is diaphoretic. Diaphoresis is a manifestation of hypoglycemia and can lead to decreased cerebral function. The nurse should check the client's blood glucose and administer a fast-acting glucose as prescribed. A nurse is reinforcing teaching with a young adult client about testicular self-examination. Which of the following instructions should the nurse include? - Examine your testicles after a warm shower - Press each testicle inwardly with your finger - Rinse any soap off your hands before examining your testicle -Perform the self- examination every 2 month - ✔✔Examine your testicles after a warm shower After exposure to warm water in a shower or bath, the scrotum relaxes and becomes easy to palpate. The testicle should feel smooth and round, and the client should report any lumps to his provider. A nurse is collecting data from a client who has tuberculosis and started combination therapy 2months ago. Which of the following diagnostic results indicates that the client is adhering to the medication regimen. - A negative chest X-ray - A negative sputum culture -A negative tuberculin skin test -A negative titer for cytomegalovirus - ✔✔A negative sputum culture Tuberculosis is an infectious disease spread through airborne droplets. Sputum cultures are obtained to both diagnose tuberculosis and to determine whether the medication treatment has been effective. After the client begins antibiotic treatment for tuberculosis, a sputum culture is obtained monthly. A negative culture is an indication that the client is no longer infectious and the medication therapy has been effective. A nurse is collecting data from a client who has bacterial meningitis. Which of the following findings should the nurse expect? - Severe Headache - ✔✔- Severe Headache The nurse should expect a client who has meningitis to have severe and persistent headaches that worsen with movement of the head. A nurse is reinforcing with a client who has pernicious anemia. Which of the following statements by the client indicated an understanding of the teaching - I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize - ✔✔I will be able to switch to a nasal form of cyanocobalamin when my levels stabilize A nurse is reinforcing discharge teaching with a client who has COPD and reports episodes of dyspnea. Which of the following instructions should the nurse include? - Used the pursed lip breathing technique - ✔✔Used the pursed lip breathing technique A client who has COPD should use the pursed-lip breathing technique to prolong exhalation, which increases positive pressure in the lungs, decreases dyspnea, and promotes air exchange. A nurse is reinforcing teaching with a client who has varicose veins of the right lower extremity. Which of the following instructions should the nurse include in the teaching - Apply elastic support hoes before getting out of bed in the morning - ✔✔- Apply elastic support hoes before getting out of bed in the morning The nurse should instruct the client to apply elastic support hose before placing legs in a dependent position because blood vessels contain less congested blood after sleeping during the night. Varicose veins are the result of increased pressure within the vessel wall and valve, which are incompetent at promoting venous return. It manifests as aching pain and fatigue to the extremity, and it can cause visible dilation of the veins. A nurse is preparing to transfer a client from a bed to chair following a total knee arthroplasty. The client has a prescription for partial weight bearing. Which of the following actions should the nurse take - Flex at the hip and knees before transferring the client - ✔✔- Flex at the hip and knees before transferring the client A nurse is reinforcing teaching with a client who is scheduled for a thoracentesis to remove pleural fluid. Which of the following information should the nurse include in the teaching - You will lean forward on the over bed table for this procedure - ✔✔- You will lean forward on the over bed table for this procedure A thoracentesis is a therapeutic or diagnostic procedure that involves insertion of a needle into the pleural space. It can be performed at the client's bedside with the client leaning forward on pillows and across an overbed table. This position widens the intercostal spaces and makes it easier to insert the needle into the posterior chest and remove the pleural fluid. A nurse is reinforcing teaching with a newly licensed nurse about promoting sleep in older adult clients who have Alzheimer's disease. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching - I will provide the client with a light snack of cheese and crackers at bed time - ✔✔- I will provide the client with a light snack of cheese and crackers at bed time The nurse should provide the client with a light snack as part of the bedtime routine to help induce sleep. Eating a snack can prevent waking during the night due to hunger. A nurse is reinforcing teaching with a client who is in early stage stages of COPD and wants to use nicotine chewing gum to help him stop smoking. Which of the following recommendations should the nurse make - Do not eat or drink anything 15min before or after chewing the gum - ✔✔- Do not eat or drink anything 15min before or after chewing the gum The client should not eat or drink anything 15 min before, during, or 15 min after chewing the gum. Food and beverages can interfere with the absorption of nicotine and diminish its therapeutic effects as nicotine replacement therapy. A nurse is reinforcing teaching about foot care with a client who has a new diagnosis of diabetes mellitus, which of the following statements by the client indicates an understanding of the instructions - I'll prop my feet up while im watching television - ✔✔- I'll prop my feet up while im watching television Elevation promotes circulation to the client's feet. Clients who have diabetes mellitus develop changes to microvasculature, which can impair circulation. A nurse is contributing to the plan of care for a client who has a neurogenic bladder following a spinal cord injury. Which of the following interventions should the nurse include in the plan to develop bladder control - Stroke the inner thigh - ✔✔Stroke the inner thigh A client who has a spinal cord injury can experience a loss of urinary control. The injury to the spinal cord results in a neurogenic bladder, which means the client is unaware of the need to void. This can result in bladder distention, renal calculi, or autonomic dysreflexia. The nurse should monitor urinary output and implement a bladder retraining program that includes teaching the client how to trigger voiding, such as stroking the inner thigh. A nurse is reviewing the medical record of a client who has systemic lupus erythematosus. Which of the following findings should the nurse expect - Joint pain - ✔✔- Joint pain The nurse should expect a client who has SLE to exhibit manifestations such as joint pain, photosensitivity, hair loss, and malaise. SLE is an autoimmune disease that causes the body to produce antibodies that attack body cells instead of pathogens, such as bacteria and fungi. A nurse is reinforcing dietary teaching with a client who has a new diagnosis of GERD about foods to avoid because they worsen the manifestations of GERD. Which of the following foods should the nurse instruct the clients to avoid - Peppermint - ✔✔- Peppermint The nurse should remind the client that foods that relax the esophageal sphincter and thus worsen the manifestations of GERD include peppermint and spearmint. GERD is a condition in which gastric acids and gastric contents reflux into the esophagus due to delayed stomach emptying or relaxation of the lower esophageal sphincter. A nurse is planning care for a client who is receiving bolus enteral feedings and is prescribed digoxin and furosemide. Which of the following actions should the nurse take - Flush the tube with water before and after each medication - ✔✔Flush the tube with water before and after each medication The nurse should flush the tube with at least 15 mL of water before and after each medication to ensure the client receives the total dose of the medication and to reduce the risk of clogging the tube. A nurse is reinforcing teaching about the use of an Oxygen concentrator in the home for a client who has end stage emphysema. Which of the following instructions should the nurse include to promote client safety - Maintain an electrical back up system - check oxygen system weekly [Show More]

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