Partial preview of the text
Download PN VATI FUNDAMENTALS 2024 QUESTIONS AND ANSWERS 100% and more Exams Nursing in PDF only on Docsity!
1. A nurse is collecting data from a client who has an elevated temperature with no sweating. Which of the following findings is an indication of hyperna- tremia? Thirst —Muscle twitching —Headache —Abdominal cramps BB thirst. Rationale Thirst, combined with an elevated temperature and a lack of sweating, can be an indication of hypernatremia. 2. Anurse is caring for a client who reports difficulty sleeping due to the noise on the nursing unit. Which of the following actions should the nurse take to reduce environmental noise? —Close the door to the client's room. —Turn off the alarms and beeps on monitoring equipment. 1/46 —Conduct change-of-shift report outside the client's door. —Keep the television on low in the client's room. Bi close the door to the client's room. Rationale The nurse should close the door to the client's room whenever possible to reduce environmental noise. 3. A nurse is reinforcing teaching about health promotion with a client. Which of the following actions should the nurse take first to promote effective learn- ing? —Identify areas of concern. —Prioritize learning objectives. —Demonstrate psychomotor skills. —Observe nonverbal communication. Ans Identify areas of concern. Rationale The first action the nurse should take when using the nursing process is to collect data from the client. Identifying and understanding the client's concerns prior to reinforcing teaching promotes effective learning. 2/46 The greatest risk to this client is injury from a fall when getting into or out of a bed that is unstable due to malfunctioning locks. Therefore, the priority is to report and replace the bed before admitting the client to the room. 6. A nurse is reinforcing teaching about health promotion with an older adult client. Which of the following instructions to the client is an example of secondary prevention? —Participate in screenings for tuberculosis. —Follow dietary recommendations to reduce the risk for osteoporosis. —Limit alcohol intake to one drink per day. —Perform yoga exercises three times per week. BiB Participate in screenings for tuberculosis. Rationale The nurse should encourage the client to participate in screenings for tuberculosis, a secondary prevention measure. Secondary prevention measures focus on diagnosis and early intervention. 7. A licensed practical nurse (LPN) is receiving change-of-shift report for a client who had a stroke. For which of the following tasks should the nurse request assistance from a registered nurse (RN)? —Administering a cleansing enema —Staging a pressure ulcer —Inserting an indwelling urinary catheter —Performing passive range-of-motion exercises BiBstaging a pressure ulcer. Rationale Ans An LPN can collect data for the client and report findings to an RN. However, staging a pressure ulcer requires advance knowledge and skill, and is outside the scope of practice of an LPN. An RN should assess the stage of a complex wound, such as a pressure ulcer, and provide primary client teaching about pressure ulcer prevention and care. 8. A nurse is reinforcing teaching about home safety with a client who is at risk for falls. Which of the following client statements indicates an understanding of the teaching? —"I will keep my floors well waxed." —"| will take my shoes off when | come back into the house." —"I will secure all of my electrical cords to the baseboard." "I will place area rugs on my tile floors." 5/46 water for 15 seconds after having a bowel movement." Rationale Ans The nurse should inform the client to wash their hands with soap and warm water for 15 seconds to remove micro-organisms after having a bowel movement. This reduces the risk for transmitting the virus to others because hepatitis A is a virus that is transmitted via the oral-fecal route. 10. A nurse at a rehabilitation facility is assisting with the admission of a client who has left-sided hemiplegia following a stroke. Which of the following actions should the nurse take first? —Demonstrate use of the call light. —Give the client a list of assigned caregivers for the shift. —Provide the client with nonskid footwear. —Determine the client's mental status. Ans Determine the client's mental status. Rationale The first action the nurse should take using the nursing process is to collect data from the client. By determining the client's mental status, the nurse can determine whether the client has an increased risk for injury. Confusion and disorientation can impair the client's judgment and can place the client at risk for falls. 11. Anurse is collecting data from an older adult client. Which of the following findings is 7/4 an indication of infection? —Decreased pulse rate —Urinary retention —Change in mental status —Decreased respiratory rate Bi change in mental status. Rationale The nurse should identify that changes in the client's mental status, such as con- fusion and agitation, might be manifestations of infection in an older adult client. Typical manifestations of infection might not occur with an older adult client. 12. Anurse is performing a finger stick blood glucose test on a client who has diabetes. Which of the following actions should the nurse take? —Puncture the side of the finger. —Squeeze the hand and finger tightly. —Smear the blood on the end of test strip. Hyperkalemia increases gastric activity with diarrhea, nausea and/or vomiting. Hy- perkalemia is manifested by a decreased heart rate with an ECG that has peaked T-waves and a widened QRS, which can progress to cardiac arrest. 14. A charge nurse is reinforcing teaching about ethics with a group of newly licensed nurses. The nurse uses the example of performing CPR on a client who has a do-not- resuscitate (DNR) order. Which of the following ethical principals is being violated in this example? —Justice —-Veracity —Fidelity —Autonomy Ans Autonomy. Rationale The nurse should identify that autonomy is the obligation of a nurse to respect the client's right to make health care decisions. Performing CPR for a client who has a DNR order is unethical because it violates the client's wishes. 15. A nurse is preparing to perform suctioning for a client who has a tra- cheostomy tube. Which of the following materials should the nurse obtain? —A size 18 French suctioning catheter —Silicone-based lubricant —Oral airway device —Resuscitation bag Hi Resuscitation bag. Rationale Ans The nurse should have a resuscitation bag connected to 100% oxygen available to provide supplemental oxygen to the client during tracheal suctioning to reduce the risk for hypoxia. If the client does not have a large amount of secretions, the nurse should hyperventilate the client's lungs with 100% oxygen three to five times before and after suctioning. If the client develops respiratory distress during the procedure, the nurse should provide manual breaths and supplemental oxygen with the resuscitation bag. 16. A nurse is reinforcing teaching with a group of adolescent clients about testicular self-examination. Which of the following instructions should the nurse include? —Plan to start performing the exam at 21 years of age. —Take a warm shower before performing the exam. —Perform the exam every 3 months until 50 years of age. —Feel for lumps by squeezing the testicles against the inner thigh. Bi Take a warm shower before performing the exam. 11/46 —The client has a 2.5 cm (1 in.) reddened area on their sacrum. —The client has a blood pressure of 150/90 mm Hg. Wii The client reports experienc- ing a headache. Rationale Ans The nurse should document the client reporting a headache as subjective data in the client's medical record. Subjective data is information obtained from the client and consists of his perception of his experience or conditions. 18. A nurse is caring for a client who has vancomycin-resistant enterococci (VRE) ina wound. Which of the following actions should the nurse take to control the transmission of this infection? —Remove gloves outside the client's room. —Wear a gown when assisting the client with hygiene care. —Wash hands for 10 seconds using an antimicrobial soap. -Wear amask or a respirator when giving direct care to the client. Wi Wear a gown when assisting the client with hygiene care. Rationale Clients who have VRE require contact precautions. The nurse should wear gloves and a gown when assisting the client with hygiene care to reduce the risk of transmitting the infection. 19. Anurse is assisting in the plan of care for a client who has a closed-wound drainage system. Which of the following interventions should the nurse in- clude in the plan? 13/46 Release hand pressure before replacing the drainage plug. —Wear surgical gloves when emptying the drainage device. —Wipe the port with soap and water before closing the drain. -€ompress the bulb to re-establish constant low negative pressure. Hi compress the bulb to re-establish constant low negative pressure. Rationale The nurse should include in the plan of care to compress the bulb as needed to re- establish a constant low negative pressure that will work as a closed suction to draw secretions into the bulb. Tips Biithe nurse should include in the plan of care to maintain hand pressure while replacing the drainage plug to create negative pressure, wear clean gloves while 14/46 —A clinical nurse specialist (CNS) —A nurse educator Ans RN, CNS, and Nurse Educator. Rationale Aregistered nurse (RN), is correct because developing a teaching plan is within the scope of practice for the registered nurse. A clinical nurse specialist (CNS), is correct because developing a teaching plan is also within the scope of practice for the clinical nurse specialist and the CNS is and advanced practice nurse who has expertise in a particular clinical area. ANurse Educator, is correct because developing a teaching plan is within the scope of practice for the nurse educator. A nurse educator is a registered nurse who is prepared to teach in various areas of nursing and patient care. 16/46 22. A nurse is caring for a client who is 1 day post operative following an abdominal hysterectomy. The client states, " | am so sad that | can't have any more children." Which of the following is a therapeutic response by the nurse? —"This feeling will go away with time." —"lam sorry to hear that you feel that way." —"You should focus on healing right now." —"L will stay with you while we talk some more about this." HB"! will stay with you while we talk some more about this." Rationale The nurse should remain with the client to listen to their feelings and concerns. This action is a form of active listening and a therapeutic response. 23. A nurse is caring for a client who has a terminal illness. Which of the following is an expected response by a family member during the anger stage of grieving? —The family member criticizes care provided by the nurse. —The family member changes the subject when the client mentions their illness. —The family member expresses grief about the past. The family member talks about how much the client will be missed. Bi the family member criticizes care provided by the nurse. Rationale Rationale Swelling, coolness, paleness, and discomfort at the infusion site indicate infiltration. The nurse should stop the infusion and discontinue the IV line. 25. A licensed practical nurse (LPN) is planning care for a group of clients a the beginning of a shift. For which of the following clients should the nurse request a change in assignment? —A client who needs a wound culture. —A client who needs an indwelling urinary catheter removed. —A client who requires evaluation of an established plan of care. -A client who requires an intermittent enteral feeding. Ba client who requires an evaluation of an established plan of care. Rationale Evaluating an established plan of care for a client requires advanced nursing knowledge and skill and is outside the scope of practice of an LPN. It is within the scope of practice of an LPN to assist in establishing the plan of care for a client. 26. A nurse discovers a fire in the trash can in a client's room. After removing the client from the room, which of the following actions should the nurse take next? —Pull the pin on the fire extinguisher. —Activate the fire alarm. —Turn off oxygen supply in client rooms. —Close the client's door. Bi Activate the fire alarm. Rationale The greatest risk to the client and to other clients is injury from the fire; after removing the client from the room, the priority action the nurse should take is to activate the fire alarm. Tip Ans FOR FIRE SAFETY THINK OF RACE. 27. Anurse is contributing to the plan of care for a client who is receiving con- tinuous enteral nutrition. The client has a prescription for 2,000 calories/day. The high-calorie enteral formula the client is receiving, provides 2 calories/mL. How many mL/hr should the client receive? (Round answer to nearest whole number.) BS 22 mL/hr. Rationale Ans Using the drip factor formula, determine whether the amount to infuse 
