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VATI Adult Medical Surgical
A nurse is collecting data from a client who has acute cholecystitis. Which of the following manifestations should the nurse expect? - Answer-Pain radiating to the right shoulder.
A nurse is reinforcing teaching with a client who has a prescription for clopidogrel following a thrombotic stroke. Which of the following information should the nurse include in the teaching? - Answer-"The medication prevents clot formation."
A nurse is contributing to the plan of care for a client who is in skeletal traction. Which of the following interventions should the nurse include? - Answer-Keep the client's body centered in the bed.
A nurse is administering a tap water enema to a client who has constipation. The client reports abdominal cramping during installation of the enema. Which of the following actions should the nurse take? - Answer-Slow the rate of fluid flow.
A nurse is reinforcing teaching about mammograms which an adult client who is postmenopausal. Which of the following statements indicates to the nurse that the client understands the teaching? - Answer-"I should have a mammogram every 1 to 2 years."
A nurse is collecting data from a client and osculates intermittent high-pitched sounds during inspiration over the lower base of the lungs. The nurse should identify this finding as which of the following lung sounds? - Answer-Fine crackles
A nurse is assisting with the care of four clients. Which of the following clients is the priority for the nurse to see? - Answer-A client who has chest tubes and an oxygen saturation of 90%
A nurse is preparing to perform a closed irrigation of an indwelling urinary catheter for a client who had abdominal surgery. Which of the following actions should the nurse plan to take? - Answer-Stop the irrigation if resistance is felt during fluid instillation.
A nurse is contributing to the plan of care for a client who has dysphagia following a stroke. Which of the following actions should the nurse include in the plan of care to prevent aspiration? - Answer-Keep the client upright for 30 min after a meal.
A nurse is reinforcing postoperative teaching with a client who is scheduled for cataract surgery on his right eye. Which of the following instructions should the nurse include? - Answer-"Wear a protective eye shield while sleeping."
A nurse is collecting data from a client who was admitted with a Glasgow coma scale (GCS) of 3. Which of the following findings should the nurse expect? - Answer-Nonresponsive to commands.
A nurse is caring for a client who has type 1 diabetes mellitus and has undergone a below-the-knee amputation. Which of the following is the highest priority finding? - Answer-Skin flap of the residual limb is cool to the touch.
A nurse is reinforcing teaching about the prevention of sexually transmitted infections (STIs) which a client who is sexually active. Which of the following information should the nurse include in the teaching? - Answer-Inserting a polyurethane female condom is effective for prevention of STIs.
A nurse is reviewing the medical record of a client who has systemic lupus erythematous (SLE). Which of the following findings should the nurse expect? - Answer-Joint pain
A nurse is preparing to transfer a client from a bed to a chair following a total knee arthroplasty. The client has a prescription for partial weight bearing. Which of the following actions should the nurse take? - Answer-Position feet apart before pivoting the client.
A nurse is collecting data from a client who has diabetes myelitis and a blood because level of 61 mg/dL. Which of the findings should the nurse expect? - Answer-Difficulty concentrating.
The nurse is reinforcing teaching with a client who has a history of calcium oxalate kidney stones. Which of the following statements by the client indicates an understanding of the instructions? - Answer-"I'll be sure to eliminate peanuts from my diet."
A nurse is caring for a client who is receiving bolus enteral feedings and is prescribed digoxin and furosemide. Which of the following actions should the nurse take? - Answer-Flush the tube with water before and after each medication.
A nurse is reinforcing teaching with a client who is scheduled for an electroencephalogram (EEG). Which of the following information should the nurse include in the teaching? - Answer-"Shampoo your hair the night before the procedure."
A nurse is caring for a client who has a new diagnosis of moderate Alzheimer's disease. Which of the following provider prescriptions should the nurse expect? - Answer-Donepezil 5mg PO daily
A nurse is collecting data from a client who has left homonymous hemianopsia following a stroke. Which of the following client findings indicates effective management of homonymous hemianopsia? - Answer- Eats items from both sides of the lunch tray.
Nurse is collecting data from a client who has a new ileostomy. Which of the following findings about the Stoneman said the nurse report to the provider? - Answer-Purple in appearance.
A nurse is contributing to the plan of care of a client who has neurogenic bladder following a spinal cord injury. Which of the following intervention should the nurse include in the plan to develop bladder control? - Answer-Stroke the inner thigh.
A nurse is caring for a client who has burns to the face, neck, and upper chest. The client has expressed concerns regarding the change to the physical parents. Which of the following actions should the nurse take? - Answer-Encourage the client to ask questions about their treatment.
The nurse is caring for a client who is receiving peripheral IV therapy. The nurse notes that the IV site is red, warm, and painful to the touch. Which of the following actions should the nurse take? - Answer- Discontinue the IV and apply a warm almost, compress to the site.
A nurse is caring for a client who has deep vein thrombosis. Which the following actions should the nurse take to promote venous return? - Answer-Maintain the use of compression stockings except when bathing the client.
A nurse is reviewing the medical record for a client who has new prescription for a combined oral contraception. Which of the following findings is a risk factor for the development of thromboembolism? - Answer-Cigarette smoking
A nurse is reinforcing teaching with a client who has chronic renal failure and is prescribed epoetin alfa. Which of the following information should the nurse include in the teaching? - Answer-"Epoetin alfa can reduce your need for a blood transfusion."
A nurse is preparing to assist with a client who is scheduled for a bronchoscopy. Which of the following action should the nurse take? - Answer-Administer supplemental oxygen
A nurse is contributing to the plan of care for a client who had a stroke and is experiencing dysphasia. Which of the following intervention should the nurse include in the plan? - Answer-Keep the client's glasses of liquid at least two-thirds full.
A nurse is collecting data from a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse expect? - Answer-Fruity breath odor.
A nurse is reinforcing teaching with a client who has hypertension and a prescription for lisinopril. Which of the following information should the nurse include in the teaching? - Answer-Report a persistent, dry cough
