VATI Comprehensive A_ answered updated fall 2021/2022. All Questions with Accurate answers. Graded A+

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A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of the foll... owing actions should the nurse take? A. Rupture the amniotic sac B. Medicate the client for pain C. Prepare the client for a cesarean section D. Perform a vaginal exam - ✔✔Prepare the client for a cesarean section A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which of the following statements should the nurse document in an incident report? A. Client fell out of bed because an assistive personnel left the rails of the bed down B. Client's roommate thinks the client is confused and fell when getting out of bed C. Client appears to have slipped in water but reports no injuries D. Client found lying on the floor near the bedside table - ✔✔Client found lying on the floor near the bedside table 178. A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit. Which of the following clients is appropriate to assign to the float nurse? A. A 10-year-old client who has pneumonia and is receiving respiratory treatments B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect tomorrow D. A 14-year-old client who is scheduled for discharge today following placement of a Herrington rod - ✔✔A 10-year-old client who has pneumonia and is receiving respiratory treatments 179. A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions? A. Hepatotoxicity B. Ototoxicity C. Hypercalcemia D. Hypertension - ✔✔Ototoxicity 180. A nurse is assessing an infant who has water intoxication. Which of the following findings should the nurse expect? A. Generalized edema B. Elevated urine specific gravity C. Thready pulse D. Increased hematocrit - ✔✔Thready pulse 1. A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client has two school-age children and a limited support system. Which of the following is the priority nursing action? A. Inform the client of available community resources B. Assist the client in finding child care options C. Agree upon short-term goals for the client D. Ask the client about their understanding of the diagnosis - ✔✔Inform the client of available community resources 2. A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture? A. Clear fluid drainage from the nares B. Report of pain around the eyes C. Dried blood in the mouth D. Mandibular asymmetry - ✔✔Clear fluid drainage from the nares 3. A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks of gestation and has bacterial vaginosis. The nurse should recognize that which of the following clinical findings are associated with this infection? A. Profuse milky white discharge B. Frequency and dysuria C. Low-grade fever D. Hematuria - ✔✔Profuse milky white discharge 4. A nurse is discussing the z-track administration of hydroxyzine with a newly licensed nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of the technique? A. This technique prevents injury to the sciatic nerve B. This technique decreases the risk of subcutaneous infiltration C. This technique allows a larger amount of medication to be injected D. This technique increases the absorption rate of the drug - ✔✔This technique decreases the risk of subcutaneous infiltration 10. A nurse is caring for a full-term newborn immediately following birth. Which of the following actions should the nurse take first? A. Instill erythromycin ophthalmic ointment in the newborn's eyes B. Weigh the newborn C. Place identification bracelets on the newborn D. Dry the newborn - ✔✔Dry the newborn 11. A nurse is planning to provide community education about viral hepatitis. Which of the following should the nurse plan to include in the teaching? A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis B. Hepatitis B is transmitted by contaminated food C. Chronic hepatitis can lead to renal cell cancer D. Clients who have a history of viral hepatitis are unable to donate blood - ✔✔Clients who have a history of viral hepatitis are unable to donate blood 12. A nurse in a residential mental health facility is planning care for a new client who has obsessive compulsive disorder. Which of the following is appropriate for the nurse to include in the plan of care? A. Work with the client to create a flexible daily schedule B. Gradually decrease the time allowed for ritualistic behavior C. Offer solutions to assist in problem solving D. Teach the client to meditate about obsessive thoughts - ✔✔Work with the client to create a flexible daily schedule 13. A nurse is assessing an adult male who has a BMI of 20. The nurse should identify that the client's BMI falls within which of the following categories? A. Healthy weight B. Malnutrition C. Overweight D. Obesity - ✔✔Malnutrition 14. A nurse is caring for a client who is nulliparous and in the first stage of labor. The last internal assessment revealed 100% cervical effacement with 5 cm of dilation. At the end of the last contraction, the nurse observes a large gush of fluid coming out of the client's perineal area. Which of the following is a priority action by the nurse? A. Perform another internal exam B. Notify the client's provider C. Check the FHR D. Obtain a pH test of the fluid - ✔✔Check the FHR 15. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan? A. Encourage the client to gain 2.3 kg per week B. Weigh the client once per week throughout hospitalization C. Monitor the client for 1 hr after meals D. Allow the client to choose meal times - ✔✔Monitor the client for 1 hr after meals 16. A nurse is performing a skin assessment on a client who has risk factors for development of skin cancer. The nurse should understand that a suspicious lesion is A. Asymmetric, with variegated coloring B. Scaly and red C. Brown, with a wart-like texture D. Firm and rubbery - ✔✔Asymmetric, with variegated coloring 17. A nurse is assessing a client's internal eye structures with an ophthalmoscope. Which of the following actions should the nurse take? A. Position the examination light toward the client's face B. Stand on the right side of the client when examining the left eye C. Dim the lights in the room prior to the examination D. Place the ophthalmoscope directly against the client's forehead - ✔✔Dim the lights in the room prior to the examination 18. A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the following actions should the nurse identify as an indication that the newly licensed nurse understands wound irrigation? A. Cleanses the wound with povidone-iodine with cotton balls B. Administers PO analgesia 20 min prior to irrigation C. Warms the irrigation solution in the microwave oven prior to application D. Irrigates the wound from the top to the bottom - ✔✔Administers PO analgesia 20 minutes prior to irrigation 19. A nurse is planning care for a child who has increased intracranial pressure with a decrease in level of consciousness. Which of the following interventions should the nurse include in the plan of care? A. Perform active range-of-motion exercises B. Maintain the head at a midline position C. Suction the airway frequently D. Perform neurological checks every 4 hrs - ✔✔Maintain the head at a midline position 20. A nurse notices smoke coming from a client's room and discovers a fire in the wastebasket. After moving the client to safety, which of the followings is the priority action? A. Notify the facility operator B. Close the fire doors on the unit C. Turn off oxygen sources D. Put out the fire with the appropriate extinguisher - ✔✔Close the fire door on the unit 21. A nurse is talking with an adult child of a client who was involuntarily admitted to an inpatient mental health facility. Which of the following statements should the nurse make? A. The provider will notify your patient's employer about admission to the facility B. Your parent will have to take the medication that the doctor prescribes C. Your parent might have electroconvulsive therapy without providing consent D. The provider can prescribe restraints if your parent tries to harm others - ✔✔The provider can prescribe restraints if your parent tries to harm others 22. A nurse is assessing a client who has delirium due to a febrile illness. Which of the following findings should the nurse expect? A. Hallucinations B. Agnosia C. Bradycardia D. Aphasia - ✔✔Hallucinations 23. A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings indicates fluid overload? A. Diminished bowel sounds B. Bradycardia C. Hypotension D. Bounding pulses - ✔✔Bounding pulses 24. A nurse is caring for a client following an open colectomy. Which of the following findings places the client at risk for delayed wound healing? A. INR 1.1 B. Hyperemesis C. HbA1c 5.6% D. Uncontrolled pain - ✔✔Hyperemesis 25. A nurse is assessing a client who has a complete heart block and is receiving transcutaneous pacing. Which of the following findings indicates to the nurse that the treatment is effective? A. Heart rate greater than 60/min B. Pedal pulses 2+ C. Pacer spikes after the QRS complex D. Distended jugular veins - ✔✔Heart rate greater than 60/min 26. A nurse is caring for a client who is taking levothyroxine. Which of the following findings should indicate to the nurse that the medication is effective? A. Decreased blood pressure B. Weight loss C. Decreased inflammation D. Absence of seizures - ✔✔Weight loss 27. A nurse at the family planning clinic triages several client over the phone. Which of the following clients should the nurse instruct to come to the clinic? A. A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting B. A client who had an intrauterine device inserted yesterday and has cramping and bleeding C. A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding D. A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday - ✔✔A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday 28. A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse should evaluate which of the following laboratory tests to determine effective long-term management of blood glucose levels? A. 3-hr oral glucose tolerance test B.. HbA1c C. Fasting blood glucose test D. Urinalysis for ketones - ✔✔HbA1C 29. A nurse is caring for a client who has neutropenia due to HIV. Which of the following precautions should the nurse take while caring for this client? A. Wear an N95 respirator B. Insert an indwelling urinary catheter to monitor urinary output C. Monitor the client's vital signs every 8 hr D. Use a dedicated stethoscope - ✔✔Use a dedicated stethoscope 30. A nurse is planning care for a client who has a gambling disorder. Which of the following instructions should the nurse provide to the client? A. Participate in a 12-step program B. Plan to take clozapine for the next 6 months C. Use systematic desensitization to decrease gambling behaviors D. Learn to use projection to adapt to stressful experiences - ✔✔Participate in a 12-step program 31. A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following actions should the nurse take? A. Encourage the client to ambulate in the hallway 1 hr before bedtime B. Tell the client to avoid drinking fluids 1 hr before bedtime C. Schedule routine care tasks during hours when the client is awake D. Advise the client to leave the television in the room on when trying to fall asleep - ✔✔Tell the client to avoid drinking fluids 1 hr before bedtime 32. A nurse is planning care for a newborn who has hyperbilirubinemia and is to receive phototherapy. Which of the following interventions should the nurse include? A. Clothe the newborn in light cotton B. Check the newborn's temperature every 8 hrs. C. Administer 120 mL of water between feedings [Show More]

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