VATI Basic Care and Comfort Quiz - Questions, Answers and Rationale

VATI Basic Care and Comfort Quiz A nurse is teaching parents how care for their newborn. Which of the following statements indicates a good underst anding of how to use a bulb syringe to suction excess mucous from the i ...

VATI Basic Care and Comfort Quiz A nurse is teaching parents how care for their newborn. Which of the following statements indicates a good underst anding of how to use a bulb syringe to suction excess mucous from the infant's airway? Select one: a. "The bulb syringe should reach to the back of my baby's throat." b. "I should compress the bulb syringe after I place it in my baby's mouth." c. "I should suction my baby's mouth before the nose." d. "The bulb syringe should be sterilized after each use." - Ans-c. "I should suction my baby's mouth before the nose." Rational: The mouth should always be suctioned before the nose to prevent aspiration during the gasp response that occurs when the nose is suctioned. The parent of a two-year-old child reports feeling frustrated with the fact that her son is saying no to everything. The nurse should teach the parent that this behavior is a normal expression of the child's desire to accomplish which of the following? Select one: a. Gratify their oral fixation. b. Finish a project they set out to do. c. Develop their sense of trust. d. Increase their independence. - Ans-d. Increase their independence. Rational: The drive for independence is expressed by the toddler opposing the desires of those in authority (tantrums) and attempting to do everything for themselves. The Erickson developmental stage for this age is "Autonomy vs. Shame and Doubt."At a well-child visit, the parents report that their toddler occasionally touches and fondles her genital area. The parents ask the nurse if this behavior is something to be concerned about. Which of the following is a correct response? Select one: a. This is an early emergence of sexual expression that should be discouraged b. This is a possible infection or irritation in the genital area c. Your child is probably imitating behaviors that she has observed d. Awareness of body structures and sensations is normal and expected - Ans-d. Awareness of body structures and sensations is normal and expected Rational: Genital self-stimulation by the toddler is normal and expected. It is a new area to explore, similar to exploring the toes at an earlier age, but it has pleasurable sensations too! It should be ignored unless the behavior becomes pervasive, and then it should still be ignored and the child should be distracted to come and do some fun and exciting activity A nurse is completing a dietary evaluation for a client diagnosed with acute glomerulonephritis. Which of the following statements made by the client demonstrates understanding of necessary restrictions? Select one: a. "I should consume a diet low in carbohydrates." b. "I should increase my consumption of protein." c. "I should limit my sodium intake to 4 grams per day." d. "I should increase my fluid intake to 8-10 glasses of water a day." - Ans-c. "I should limit my sodium intake to 4 grams per day." Rational: Excessively high protein and sodium diets put clients at risk for glomerulonephritis. Clients with this condition should implement sodium and protein restriction. A nurse is assisting a client with bowel training. When should the nurse instruct the client to attempt defecation?Select one: a. Every hour while awake. b. Immediately before meals. c. When the client feels abdominal cramping. d. When the client has the urge to defecate. - Ans-d. When the client has the urge to defecate. CORRECT. Failure to heed the call to defecate may lead to overdistention of the rectum with hardening of the stool and subsequent constipation. Therefore, the best time to toilet a client to encourage bowel training is when the client has the urge to defecate. A nurse is calculating the client's intake and output. Based on the information below, which of the following values correctly represents the client's total output? Sipped 8 oz. clear broth. 100 mL ice chips. Voided 450 mL. IV push pain medication 50 mL. Drank 4 oz. juice and 6 oz. hot tea. Vomited 120 mL and voided 600 mL. Jackson Pratt drain emptied 40 mL. Select one: a. 1210 mL b. 1068 mL c. 590 mL d. 680 mL - Ans-a. 1210 mL Rational: 1210 mL output is the correct value. Input includes all liquids taken by mouth, including through nasogastric or jejunostomy feeding tubes, IV fluids, and blood or its components. Output includes urine, diarrhea, vomitus, and drainage from tubes such as through gastric suction and drainage from postsurgical wounds or other tubes.A nurse is providing dietary education for a client with cholecystitis. Which of the following food choices made by the client indicates a need for further teaching? Select one: a. Chicken breast b. Baked potato c. Broccoli with cheese sauce d. Wheat bread - Ans-c. Broccoli with cheese sauce CORRECT. Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and releases bile that aids in the digestion of fats. Fat intake should be limited to reduce stimulation of the gallbladder. Other foods that may be contraindicated include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods. A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification? Select one: a. "I will clean his penis with each diaper change." b. "I can give him a tub bath in two days." c. "The circumcision will heal completely within a couple of weeks." d. "I should not remove the yellow exudate on the end of the penis." - Ans-b. "I can give him a tub bath in two days." Rational: The newborn should not be immersed in water until the circumcision has healed and the umbilical cord has detached. The circumcision should heal within two weeks. A graduate nurse is performing ostomy care for a client with a new colostomy. Which intervention performed by the nurse indicates the need for more education?Select one: a. Changing the pouch before a meal. b. Positioning the client standing or supine. c. Cleansing the peristomal skin with alcohol. d. Measuring and assessing the stoma. - Ans-c. Cleansing the peristomal skin with alcohol. Rational: This intervention is not appropriate. The peristomal skin should not be cleansed with alcohol. A nurse is discussing the use of condoms with a female client. Which of the following statements by client represents a need for further teaching? Select one: a. "My partner should leave an empty space at the tip." b. "I will remove the condom 30 minutes after intercourse." c. "My partner will put the condom on while his penis is erect." d. "I can use spermicidal gels or creams to increase effectiveness." - Ans-b. "I will remove the condom 30 minutes after intercourse." Rational: To avoid any semen spillage onto the vulva or the vaginal area, the condom must be removed the same time as the penis. To do that the condom rim should be held in place while the penis is withdrawn from the vagina. A nurse is educating a client who observes Kosher laws of food preparation. When planning menus with this client, which of the following would not be an appropriate food choice? Select one: a. Rabbit b. Eggs c. Tuna d. Spinach - Ans-a. RabbitCORRECT. Of the "beasts of the earth" (which basically refers to land mammals with the exception of swarming rodents), clients observing Kosher laws may eat any animal that has cloven hooves and chews its cud. Any land mammal that does not have both of these qualities is forbidden. The Torah specifies that the camel, the rock badger, the hare and the pig are not kosher because each lacks one of these two qualifications. Cattle, sheep, goats, deer and bison are kosher.