MEDSURG VATI ASSESSMENT 90 Q'S
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A nurse is assisting with the care of four clients. Which of - A client who has chest tubes and an oxygen Sat of 90%
the following clients is the priority for
the nurse to see Using the airway, breathing, and circulation approach to client care, the nurse
should determine that the priority finding is the client's oxygen saturation level,
-A client who has chest tubes and an oxygen Sat of 90% which is below the expected reference range of 95% to 100%. Therefore, the nurse
- aclient who has peripheral edema and urinary output of should attend to this client first.
130 over 4hrs
- A client who has a permanent pacemaker with heart
rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4
A nurse is collecting data from a client who was admitted Nonresponsive Commands
with a Glasgow Coma Scale of 3. Which
of the following findings should the nurse expect? A client who has a GCS of less than 8 has evidence of severe head injury and is in
- Vacalizes sound a comatose state. The GCS is a standardized tool that allows for the evaluation of
-Blinks eyes when asked a client's level of consciousness. The test is divided into three sections that
-Follows motor commands evaluate eye opening, motor response, and verbal response. The GCS ranges
-Nonresponsive Commands from a high score of 15 (fully alert) to a low score of 3 (fully comatose).
A nurse is monitoring a client who has a pneumothorax - Persistent bubbling in the water seal chamber
and a chest tube in place with a closed chest drainage
system connected to low suction. For which of the Excessive and persistent bubbling in the water-seal chamber indicates an air leak
following findings should the nurse notify the charge in the drainage system. The nurse should notify the charge nurse of this finding.
nurse
- Fluctation of the water level in the water seal chamber
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber
, A nurse is reinforcing teaching with a male client who has Comb your hair with the unaffected arm
right sided hemiparesis about
preforming ADL's. Which of the following instructions The nurse should instruct the client to brush their hair with the unaffected arm to
should the nurse include in the teaching reduce frustration and increase independence and self-esteem.
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side
A nurse is collecting data from a client and auscultates - Fine crackles
intermittent high-pitched sounds during inspiration over
the lower base of the lungs. The nurse should identify this Fine crackles are auscultated in the base of the lungs as air moves through airway
finding as which of the following lungs sounds secretions. Fine crackles are intermittent, high-pitched sounds heard more often
during inspiration.
- Fine crackles
-stridor
-rhonchi
-friction
A nurse is collecting data from a client who has coronary - Chest Discomfort Radiated
artery disease. Which of the following - Pain lasting less that 15mins
manifestations should the nurse identify as an indication - Pain that is relieved with res
that the client has angina ( SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with rest
A nurse is receiving change-of-shift report for a group of A client who has diabetes mellitus with diaphoretic
clients. Which of the following clients
should the nurse plan to see first? When using the urgent vs. nonurgent approach to client care, the nurse should
- A client who has diabetes mellitus with diaphoretic determine that the priority action is to attend to a client who has diabetes mellitus
and is diaphoretic. Diaphoresis is a manifestation of hypoglycemia and can lead to
decreased cerebral function. The nurse should check the client's blood glucose
and administer a fast-acting glucose as prescribed.
A nurse is collecting data from a client who has A negative sputum culture
tuberculosis and started combination therapy
2months ago. Which of the following diagnostic results Tuberculosis is an infectious disease spread through airborne droplets. Sputum
indicates that the client is adhering to the cultures are obtained to both diagnose tuberculosis and to determine whether
medication regimen. the medication treatment has been effective. After the client begins antibiotic
- A negative chest X-ray treatment for tuberculosis, a sputum culture is obtained monthly. A negative
- A negative sputum culture culture is an indication that the client is no longer infectious and the medication
-A negative tuberculin skin test therapy has been effective.
-A negative titer for cytomegalovirus
A nurse is collecting data from a client who has bacterial - Severe Headache
meningitis. Which of the following
findings should the nurse expect? The nurse should expect a client who has meningitis to have severe and persistent
- Severe Headache headaches that worsen with movement of the head.
Save
Students also studied
IV Anesthetics and Adjuvants: Opioi... Salem Anesthesia Rotation: Clinical ... Surgical Nursing Worksheet Questio... Wound
16 terms 45 terms 29 terms 105 term
Laura_Romero25 Preview watsonryan907 Preview Karah_Ritter Preview Ash
A nurse is assisting with the care of four clients. Which of - A client who has chest tubes and an oxygen Sat of 90%
the following clients is the priority for
the nurse to see Using the airway, breathing, and circulation approach to client care, the nurse
should determine that the priority finding is the client's oxygen saturation level,
-A client who has chest tubes and an oxygen Sat of 90% which is below the expected reference range of 95% to 100%. Therefore, the nurse
- aclient who has peripheral edema and urinary output of should attend to this client first.
130 over 4hrs
- A client who has a permanent pacemaker with heart
rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4
A nurse is collecting data from a client who was admitted Nonresponsive Commands
with a Glasgow Coma Scale of 3. Which
of the following findings should the nurse expect? A client who has a GCS of less than 8 has evidence of severe head injury and is in
- Vacalizes sound a comatose state. The GCS is a standardized tool that allows for the evaluation of
-Blinks eyes when asked a client's level of consciousness. The test is divided into three sections that
-Follows motor commands evaluate eye opening, motor response, and verbal response. The GCS ranges
-Nonresponsive Commands from a high score of 15 (fully alert) to a low score of 3 (fully comatose).
A nurse is monitoring a client who has a pneumothorax - Persistent bubbling in the water seal chamber
and a chest tube in place with a closed chest drainage
system connected to low suction. For which of the Excessive and persistent bubbling in the water-seal chamber indicates an air leak
following findings should the nurse notify the charge in the drainage system. The nurse should notify the charge nurse of this finding.
nurse
- Fluctation of the water level in the water seal chamber
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber
, A nurse is reinforcing teaching with a male client who has Comb your hair with the unaffected arm
right sided hemiparesis about
preforming ADL's. Which of the following instructions The nurse should instruct the client to brush their hair with the unaffected arm to
should the nurse include in the teaching reduce frustration and increase independence and self-esteem.
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side
A nurse is collecting data from a client and auscultates - Fine crackles
intermittent high-pitched sounds during inspiration over
the lower base of the lungs. The nurse should identify this Fine crackles are auscultated in the base of the lungs as air moves through airway
finding as which of the following lungs sounds secretions. Fine crackles are intermittent, high-pitched sounds heard more often
during inspiration.
- Fine crackles
-stridor
-rhonchi
-friction
A nurse is collecting data from a client who has coronary - Chest Discomfort Radiated
artery disease. Which of the following - Pain lasting less that 15mins
manifestations should the nurse identify as an indication - Pain that is relieved with res
that the client has angina ( SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with rest
A nurse is receiving change-of-shift report for a group of A client who has diabetes mellitus with diaphoretic
clients. Which of the following clients
should the nurse plan to see first? When using the urgent vs. nonurgent approach to client care, the nurse should
- A client who has diabetes mellitus with diaphoretic determine that the priority action is to attend to a client who has diabetes mellitus
and is diaphoretic. Diaphoresis is a manifestation of hypoglycemia and can lead to
decreased cerebral function. The nurse should check the client's blood glucose
and administer a fast-acting glucose as prescribed.
A nurse is collecting data from a client who has A negative sputum culture
tuberculosis and started combination therapy
2months ago. Which of the following diagnostic results Tuberculosis is an infectious disease spread through airborne droplets. Sputum
indicates that the client is adhering to the cultures are obtained to both diagnose tuberculosis and to determine whether
medication regimen. the medication treatment has been effective. After the client begins antibiotic
- A negative chest X-ray treatment for tuberculosis, a sputum culture is obtained monthly. A negative
- A negative sputum culture culture is an indication that the client is no longer infectious and the medication
-A negative tuberculin skin test therapy has been effective.
-A negative titer for cytomegalovirus
A nurse is collecting data from a client who has bacterial - Severe Headache
meningitis. Which of the following
findings should the nurse expect? The nurse should expect a client who has meningitis to have severe and persistent
- Severe Headache headaches that worsen with movement of the head.
