RN VATI Fundamentals 2019 Assessment

1: Draw up the volume of insulin from the intermediate-acting insulin vial. 2: Inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting insulin vial. 3: Inject the volume of air equal to the insulin dose form the short-acting insulin vial 4: Withdraw the prescribed amount of insulin form the short-acting insulin vial. 5: Withdraw the prescribed amount of insulin form the intermediate-acting insulin vial.

Advise the client to rinse their mouth and dentures after each meal.

Speech-language pathologist

Position the client on the unaffected side.The nurse should position the client on the unaffected side to help facilitate expansion of the affected lung. Maintain the head of the bed at 45°.MY ANSWERSome facility protocols recommend that the nurse should raise the head of the bed to 30° for at least 30 min to facilitate expansion of the affected lung and ease of breathing. Measure the client's abdominal girth at the level of the umbilicus.The nurse should measure the client's abdominal girth following an abdominal paracentesis, rather than a thoracentesis. Leave the puncture site open to air.The nurse should apply a small, sterile dressing over the puncture site.

- Establish the client's learning needs - Determine the client's literacy level - Evaluate the client's readiness for learning - Identify the client's learning style

Previous treatments

"I will store oxygen tanks in an upright position"

"It must me a very difficult time for you."

Fear of medical test results

Identify the client using two identifiers

65 mL

Determine how the client views the concept of family

Determine the source of the client's stress

Use an alcohol-free barrier product

Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute medication with 5 mL of sterile water

Use a reflex hammer.MY ANSWER The nurse should use a reflex hammer to assess the client for clonus. The reflex hammer causes the muscle to immediately contract due to a two-neuron reflex arc involving the spinal or brainstem segment that innervates the muscle. Administer magnesium sulfate.Administering magnesium sulfate is not a test for clonus. Magnesium sulfate is administered for convulsions, hypomagnesemia, and hypertension. Perform a Romberg test.A Romberg test assesses balance, gross-motor function, and equilibrium. Test the gait for symmetry.Testing the client's gait gives the nurse information about symmetry, walking ability, posture, and balance.

A client who has chronic back pain and a history of physical maltreatment

Assist a client with ambulation

"Please use your glucometer and show me the results."

Cover the pad with a pillowcase before application. over the pad with a pillowcase before application.MY ANSWERThe nurse should cover the aquathermia pad with a thin towel or pillowcase before use because applying the pad directly to the skin could cause a burn injury. Apply the pad for 45 min per application.An application of the aquathermia pad usually lasts 30 min. Prolonged application of the pad places the client at risk for a burn injury. Set the temperature of the aquathermia pad to 50° C (122° F).The nurse should set the temperature of the aquathermia pad to 40° C (104° F). Use safety pins to hold the pad in place.The nurse should not use pins to hold the aquathermia pad in place because they can cause a leak. The nurse should use tape or gauze ties to hold the pad in place.

Rest the non-dominant hand on the clients forehead while instilling the drops. Tilt the client's head away from the side receiving the drops.The nurse should help the client assume a comfortable position, either sitting or lying, with their head tilted backward and looking up at the ceiling. Instill the drops directly onto the cornea of the eye receiving the drops.The nurse should never instill an eye medication directly onto the cornea due to the high risk for injury. Instead, the nurse should expose the lower conjunctival sac by drawing down the skin over the client's cheekbone. The nurse should then instill the prescribed number of drops onto the lower conjunctival sac. Rest the dominant hand on the client's forehead while instilling the drops.The nurse should rest the dominant hand on the client's forehead while instilling the drops. This action stabilizes the nurse's hand and ensures that the hand will move with the client if they move suddenly. This simple precaution reduces the risk of striking the client's eye with the dropper and injuring it. Hold the medication dropper 0.5 cm (0.2 in) above the conjunctival sac.MY ANSWERThe nurse should hold the medication dropper 1 to 2 cm (0.4 to 0.8 in) above the conjunctival sac. With this distance, the client is less likely to blink. Therefore, the eye drop is instilled more efficiently. It is also important to not touch the conjunctival sac or cornea.

"I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them."

Place the client in a side-lying position

Cut the sutures as close to the skin as possible. Pull the visible part of the suture through the underlying tissue.The nurse should identify that pulling the visible part of the suture through underlying tissue increases the client's risk for infection. Cleanse the wound with sterile water prior to removing the sutures.The nurse should cleanse the wound with an antimicrobial solution prior to removing the sutures. This decreases the client's risk of infection. Cut the sutures as close to the skin as possible.MY ANSWERThe nurse should cut the sutures as close to the skin as possible. The exposed part of the suture contains bacteria, so cutting close to the skin prevents bacteria from entering the clean wound, decreasing the risk for infection. Remove the sutures in a consecutive order.The nurse should remove every other suture in an alternating pattern. Removing the sutures in a consecutive order is not recommended because this could increase the risk for wound dehiscence.

"I should remove nail polish form my fingers before surgery."

Positions the client's arms across their chest.

A client who consistently coughs after drinking liquids

Decreased bowel sounds Strong, bounding pulseA weak, irregular pulse is an expected finding of hypokalemia. Positive Chvostek's signA positive Chvostek's sign is an indication of hypocalcemia or hypomagnesemia. Chvostek's sign occurs when the nurse taps the client's facial nerve, resulting in contraction of the facial muscle. Hyperactive reflexesHypoactive, or diminished, reflexes are an expected finding of hypokalemia or hypocalcemia. Decreased bowel soundsMY ANSWERDecreased bowel sounds are an indication of hypokalemia because of decreased excitability of cells, resulting in less responsiveness to normal stimuli in nerves and muscles.

D (right sternal border, second intercostal space) A is incorrect. The nurse should identify that this area is the mitral area of the cardiac landmarks, which is considered the point of maximal impulse. This is also the area in which the apical heart rate is best auscultated. This area is located at the fifth intercostal space, to the left of the sternum, at the left midclavicular line. B is incorrect. The nurse should identify that this area is the tricuspid area of the cardiac landmarks, which is located at the left fourth or fifth intercostal space, near the sternum. C is correct. The nurse should identify that this is the pulmonic area of the cardiac landmarks, which is located at the left second intercostal space, near the sternum. D is incorrect. The nurse should identify that this is the aortic area of the cardiac landmarks, which is located at the right second intercostal space, near the sternum.

Position the client on their side. Prepare to initiate antibiotic therapy.The nurse should prepare to initiate antibiotic therapy because stomach contents in the respiratory tract will likely lead to pneumonia. However, there is another action the nurse should take first. Obtain a prescription for a chest x-ray.The nurse should obtain a prescription for a chest x-ray to determine if the client aspirated stomach contents into the respiratory tract. However, there is another action the nurse should take first. Position the client on their side.MY ANSWERThe greatest risk to this client is aspiration from possible dislodgment of the NG tube and aspirated stomach contents into the respiratory tract. Therefore, the priority nursing action to decrease exacerbation of the condition is to position the client on their side. Suction the client's orotracheal airway.The nurse should suction the client's orotracheal airway to prevent further aspiration of stomach contents into the respiratory tract. However, there is another action the nurse should take first.

Wear gloves when applying the patch The nurse should apply the patch while wearing clean gloves to prevent transfer of the medication through the skin.

Obtain a RX for IV fluids The greatest risk to this client is injury from fluid volume deficit. Therefore, the first action the nurse should take is to contact the provider for a prescription to initiate IV fluid infusion. The client has assessment findings that indicate fluid volume deficit, such as an increased urine specific gravity, a decreased blood pressure, an increased temperature, and a weak pulse. The client also has increased fluid output with decreased intake as well as concentrated urine. To prevent further fluid volume deficit, the nurse's priority action is to administer IV fluids to the client.

Urinary Tract Infection According to evidence-based practice, the nurse should expect the client who has a urinary tract infection to become increasingly confused and agitated. Confusion and agitation in older adult clients often result from a systemic infection, such as a urinary tract infection or pneumonia.

-Dishwashing gloves -Adhesive tape -Bananas -Rubber bands Dishwashing gloves is correct. Many kinds of dishwashing gloves contain latex. Therefore, it places the client at risk for an allergic reaction. Adhesive tape is correct. Adhesive tape contains latex. Therefore, it places the client at risk for an allergic reaction. Macadamia nuts is incorrect. Tree nuts are a significant trigger for allergies in adults. However, macadamia nuts do not come from a source that contains latex. Bananas is correct. Certain foods such as kiwi, avocados, and bananas can trigger latex allergies. Rubber bands is correct. Rubber bands contain latex. Therefore, they place the client at risk for an allergic reaction.

Requesting a social services consult for a client who states they cannot afford their medications Requesting a social services consult for a client is an example of advocacy. The nurse is protecting the client's health by providing resources that will assist the client to receive their prescribed medications.

List of community resources The nurse should expect to find a list of community resources provided to the client in the discharge summary section. Other information the nurse should expect to find in the discharge summary section includes unresolved problems, a list of complications to report to the provider, the mode of transportation used, and who accompanied the client at discharge.

Explore the client's past coping mechanisms. The first action the nurse should take when using the nursing process is to assess the methods that the client used to successfully cope with other issues in the past and then reinforce them. This will help encourage the client to begin to learn self-care.

Monitoring a continuous intra-arterial infusion of a thrombolytic medication Monitoring the infusion of a clot-dissolving agent is within a nurse's scope of practice. In addition, the nurse should inspect the IV line for a disconnection, check the infusion site for bleeding, and maintain site integrity.

-Notify ancillary dept. of the client's allergy -Label the surgical suite as latex-free -Ensure a latex allergy care is available Schedule the client as the last surgery of the day is incorrect. A client who is allergic to latex should be the first surgery of the day. This allows overnight removal of latex dust from the previous day. Notify ancillary departments of the client's allergy is correct. Notifying ancillary departments of the client's sensitivity to latex allows the staff to take appropriate measures to ensure that medications and surgical items are not contaminated by latex. Label the surgical suite as latex-free is correct. This helps keep personnel from bringing rubber products into the room. Provide powdered gloves for the staff's use is incorrect. Powder from products containing latex can transmit allergens from the hands of health care personnel to the client. Ensure a latex allergy cart is available is correct. A latex allergy cart should be kept in the operating room at all times. All of the contents must be latex-free.

"Keep ammunition and guns in seperate, locked locations." The nurse should instruct the parents to keep ammunition in a locked cabinet separate from the firearms to reduce the risk for injury. This action will prevent access to the firearm and also prevents injury from accidental discharge because the firearm does not contain ammunition. Also, the keys to the cabinet should not be accessible to children.

Gather information to support the client's request for a DNR order. Using the nursing process, the first action the nurse should take is to assess the situation by gathering information to support the client's request for a DNR order. This information should include the client's current clinical status, factors such as the client's spirituality, culture, and family dynamics, and evidence from literature about the client's condition.

Move a vibrating tuning fork's prongs in front of the client's left or right ear canal. The nurse should perform the Rinne test by placing the handle of a vibrating tuning fork on the client's mastoid process and then moving the vibrating prongs 1 to 2 cm (0.4 to 0.8 in) in front of the client's left or right ear canal. The Rinne test compares bone conduction with air conduction. The client is expected to hear sound conduction by air for twice as long as bone conduction.

"I use space heaters to keep warm in the winter." A common environmental hazard in the home is the use of space heaters, which can increase the risk of fire.

90° The nurse should plan to insert the needle at a 90° angle when administering medication via the intramuscular route. The intramuscular route promotes quicker medication absorption into the muscle than the other routes of medication administration.

Moveable portion of the bed frame. Attaching the wrist restraints to the moveable portion of the bed frame allows the head of the bed to be raised or lowered without causing injury to the client.

A client who has dysphagia and has a scheduled feeding Using the airway, breathing, and circulation approach to client care, the priority action the nurse should take is to monitor the feeding of the client who is at risk for choking and aspiration. Therefore, the nurse should plan to see this client first.

Auscultate each of the four quadrants for 5 min before determining sounds are absent. Although it usually takes only 5 to 20 seconds to hear bowel sounds, the nurse might have to listen in all four abdominal quadrants for at least 5 min before determining that bowel sounds are absent.

Ensure oral suction equipment is at the bedside. The nurse should ensure that oral suction equipment is available at the client's bedside to prevent aspiration of oral secretions during a seizure.

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 iliac spine, and trochanter. Therefore, the nurse should ensure the client's head is midline and supported, rotation of the spine is avoided, and position changes are implemented every 1 to 2 hr

Use a reflex hammer. The nurse should use a reflex hammer to assess the client for clonus. The reflex hammer causes the muscle to immediately contract due to a two neuron reflex arc involving the spinal or brainstem segment that innervates the muscle.

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

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Ask the client whether he has created advance directives. The PSDA requires facilities to provide information to clients about their rights under state law to make decisions, including the right to refuse treatment and formulate advance directives. Under the act, staff should ask the client if they have advance directives, and the nurse should document the client's response in the medical record.

"I will place a bath mat in front of the tub." The client should place a bath mat in front of the tub because it decreases the risk for falls. The client's wet feet could become slippery and slide on the floor without a bath mat

Inspect the feet daily with a mirror The nurse should include in the program to inspect the feet daily with a mirror for dryness, redness, lesions, or lacerations, which can place the client at risk for infection.

Encourage the family member to contact the client directly for information. Nurses are legally and ethically obligated to maintain the confidentiality of client information, including the client's current health status. Therefore, the nurse should encourage the family member to contact the client directly for more information.

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 the designated form.

Change the primary IV infusion set every 96 hr. The nurse should change the primary IV infusion set every 96 hr to minimize the risk of contamination and infection. Change bag every 24 hrs

Use an air-assisted transfer device to move the client. The nurse should place an air-assisted device under the client prior to transfers to prevent injury. An airassisted transfer device is an inflatable mattress that minimizes friction to smoothly and efficiently move the client from the bed to the stretcher. In addition, at least two caregivers should assist with the transfer of a client who weighs 136 kg (300 lb).

Measure the amount of aspirate in the NG tube is incorrect. The nurse should measure the amount of aspirate in the NG tube when the client is receiving tube feedings to evaluate absorption. However, measuring the aspirate in the NG tube does not confirm placement. Placement of the NG tube must be confirmed prior to initiating feedings. Flush the tube with 50 mL of tap water is incorrect. The nurse should not instill fluid into an enteral tube until placement is confirmed. Examine the color of aspirated secretions is correct. Gastric secretions are typically cloudy, green, or tan in color. Intestinal secretions are bile-stained and therefore, typically appear yellow in color. Measure the pH of the client's aspirate is correct. Stomach contents are usually acidic, with a pH less than 5.5. A pH of 6 is an indication that the distal end of the tube is located in the intestines. A pH above 7 is an indication that the distal end of the tube is located in the respiratory tract. Obtain an x-ray of the client's chest and abdomen is correct. Radiological examination is the most reliable method of verifying the placement of a client's NG tube.

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"Cover your nose and mouth with a tissue when coughing." The nurse should instruct the client to cover their nose and mouth with a tissue when coughing. The client should discard the tissue promptly in the nearest trash container.

A

Have the client demonstrate how to use the call light. The nurse should demonstrate use of the call light for the client and ask for a return demonstration to confirm the client's understanding. This ensures the client will be able to request assistance quickly and reduces the risk for falls.

Keep the back, pelvis, feet, and neck in alignment. To reduce the risk of injury to their lower back, the nurse should align their neck, back, pelvis, and feet when lifting an object or moving a client.

B A type B fire extinguisher is appropriate for putting out flammable liquid and gas fires. Disinfectant solutions, such as isopropyl alcohol, are highly flammable liquids.

Check the client's vital signs. The first action the nurse should take when using the nursing process is to assess the client for any adverse effects of receiving the incorrect medication.

Use a nail pick to clean the fingernails under running water. Large amounts of micro-organisms can collect in dirt and organic material under fingernails. Scraping out this material and ensuring its disposal via running water is essential for surgical hand hygiene.

A client who has dementia and has removed their enteral feeding tube repeatedly Clients who have confusion and repeatedly remove or try to remove medical devices might require mitten restraints to protect themselves from injury. However, the nurse should exhaust alternative methods prior to requesting a restraint prescription.

Palpate the breasts using finger pads while the client is supine. The nurse should use their finger pads to palpate the breasts while the client is supine.

Depression The greatest mental health risk for older adult clients is depression. Therefore, this is the priority assessment to include.

Triglyceride 180 mg/dL A triglyceride level of 180 mg/dL is outside the expected reference range of 40 to 160 mg/dL for a male client and 35 to 135 mg/dL for a female client, which places the client at risk for coronary artery disease.