VATI Greenlight (questions and answers) Graded A 2022

VATI Greenlight 2 hrs post-op following an ileal conduit procedure bladder cancer ANS: Dusky-colored stoma Administering an INJ to a client even after the client states, "I don't want that injection. The last time I got that I was sore for a week." ANS: Battery Admitting a client to the medical-surgical unit. Which of the following actions should the nurse first take? ANS: Observe the client's level of mobility Adolescent client who has no previous history of a seizure disorder and is admitted after having a 3-min tonic-clonic seizure 2 wks after sustaining a mild concussion. EEG ANS: Explain that the client may not have coffee prior to the EEG Adolescent who has cystic fibrosis and has a prescription for pancrelipase ANS: Take w/ meals After evaluating the morning lab results on several clients, the provider writes prescriptions for 4 clients assigned to the nurses care? ANS: Infuse 10 meQ/l potassium chloride IV over 1 hr to a client who has potassium of 3.2 After making morning round, the charge nurse on a surgical unit delegates the follow tasks to the AP. ANS: Set up a room for an expected postoperative admission AP reports to the nurse that another ap has spent the entire morning on the phone and has not completed the morning assignment ANS: Redirect the AP to discuss the issue with the other AP Assessing client who systemic lupus erythematous SLE which of the following is an expected findings ANS: Dry, raised facial rash At the start of an evening shift on a cardiac unit, a LPN brings the nurse a list of client reports ANS: Indigestion Benefit from a three-way indwelling catheter ANS: Prone to development of blood clots un the urine Caring for a client who has a new prescription for chlorpromazine by IM injection ANS: Check orthostatic BP 1 hr after admin Caring for a client who was involved in a motor-vehicle crash. The client reports shortness of breath and chest pain and asks the nurse "Am I dying?" ANS: Admin pain meds Charge nurse creating assignments for next shift for several nurses and one of the nurses is pregnant - which pt the nurse should NOT be assigned to? ANS: 60 yr old who is recovering from shingles Charge nurse on pediatric unit is making assignments for a float nurse from the medical unit. Pt to see first? ANS: 10 yr old who has pneumonia & is receiving respiratory txs Child who has pediculosis capitis ANS: store non-washable items in plastic bags for 14 days Child who is unresponsive has ICP ANS: Pad the side of the bed A client ask the nurse if it is safe for him to take glucosamine supplement? ANS: Shellfish allergy Client following an open colectomy ANS: Uncontrolled pain A client has just returned to the nursing unit following cardiac catheterization. In the immediate postoperative post procedure period which of the following is the priority nursing actions? ANS: Immobilizing the affect extremity A client hopitialized for a bone marrow transplant is in protective isolation while undergoing total body radiation and intense chemotherapy. The clients sibling comes to visit but has obvious manifestations of an upper respiratory infection. ANS: Allow the sibling to visit after donning a sterile gown, mask, gloves but prohibits physical contact Client recovering from closed head injury assumes a decerbrate posture in response to stimuli ANS: D lying flat ?? (Extentend extremities) The client rigidly extends his arm Client reports chest pain. Which of the following lab findings indicates myocardial damage ANS: Troponin 1.8 Client who has a left femur fracture and is skeletal traction. The clients reports pain due to muscle spasms in affected leg ANS: Realign the extremity in traction Client who has given birth to a stillborn ANS: Acknowledging the reality of the newborn's death Client who is 2 days postoperative following a lumbar laminectomy and is reporting nausea ANS: Admin an antiemetic (Aprepitant for nausea) Client who is 8hr postoperative following a right-modified radical mastectomy - which findings to report to provider? (SATA) ANS: Coughing Frothy, pink secretions Client who is receiving a controlled epidural analgesia infusion ANS: Covering the insertion site with a transparent dressing Client who reports the use of chondroitin and glucosamine ANS: Improve joint functioning Community health nurse is completing a newborn home visit and observes family members smoking cigarettes in the house ANS: Review the effects of secondhand smoke w/ family members A community health nurse is evaluating eligibility for home assistance for a client who is quadriplegic ANS: Determine the client living situation A community health nurse is planning to make home visits to several clients who all live within a few miles radius of the office - Who to see first? ANS: An infant who has failure-to-thrive and was discharged from a facility yesterday to a foster home on daily weights Creating and activity plan for a home bound older adult client. In the planning, the nurse considers the physiologic changes that may affect pulmonary function r/t the normal aging process ANS: Decreased blood oxygenation Delegates the following tasks to the AP bathe four clients, distribute fresh water, obtain morning vital signs ANS: Set a clear time frame for the completion of each task DI w/ severe head injury ANS: Urine output 250 Diagnosis of antisocial personality disorder ANS: Poor impulse control Diagnosis of complete placenta previa is admitted to the labor and delivery suite at 36wks gestation w/ contractions 5 min in frequency and 1 min in duration ANS: Prepare the client for c-section Dietary intervention for a client who is immobile due to pelvic and femur fractures ANS: Provide a high-protein diet Difficulty falling asleep at night ANS: Eat a bedtime snack (containing carbohydrates??) Disaster triage following a natural disaster ANS: Amputation Discharge teaching about disease prevention to a client who has active Tb ANS: Educating the client how to cover nose and mouth with tissues when coughing Discussing a living will with a client ANS: It communicates my wishes for end of life care Discussing care w/ newly licensed nurse for a client who practices orthodox Judaism - which food not given? ANS: Roast beef and ice cream Education about ECT major depressive disorder ANS: General anesthetic admin prior ECT treatments(This treatment are for pts who aren't responding to their pharmaceutical meds) Education to the mother of a toddler who has pertussis ANS: Pertussis booster An emergency department nurse triages a group of school children injured in a school bus crash ANS: A child who reports diplopia and nausea and was unconscious at the scene but is now awake Experiencing acute mania ... ANS: Provide high-calorie nutritional supplements (provide pt with portable nutritious food because pt may not be able to sit down) Gravida 2, para 1. The client is at 41 wks gestation and is receiving oxytocin for the augmentation of labor ANS: Contractions occur every 90 sec Haloperidol for the tx of schizophrenia ANS: Screen the client for Tardive Dyskinesia (inform pt to lower doses to decrease the chances of TD) health nurse is performing a vision screening on a 4-month-old infant. When shining a light source into the infant's visual field - rx? ANS: Closes eyes Hearing impairment - incorporate which communication methods? ANS: Rephrase sentences the client doesn't understand Home health nurse is admitting a client who is prescribed peritoneal dialysis ANS: Clarify the clients actual and perceived health needs A home health nurse is conducting an initial home visit for a client who has terminal breast cancer. The client who has 2 minor children and a limited support system ANS: Ask the client about her understanding of the diagnosis A home-health nurse is providing teaching about self-administration of insulin to client who is newly diagnosed w/ diabetes mellitus ANS: I can use the same area as long as I rotate injection sites Home health nurse is reviewing treatment goals w/ a client who has diabetes mellitus evaluate lab tests to determine effective long-term management of blood glucose levels ANS: HbA1C Hyperthyroidism - which of the following rooms is appropriate for the nurse to assign this client? ANS: Cool room (reduced room temp) If something happens to me from which I cannot recover, I don't want to go on a ventilator: ANS: You're concerned that something may go wrong? Ileal conduit due to treatment for bladder cancer ANS: Cleanse w/ moisturizing soap Immediate postoperative period following thorac surgery, a nurse medicates a client for pain on a schedule ANS: Reduces the RR Infection control nurse is reviewing care procedures for four clients ANS: A client who has varicella zoster is placed in a negative pressure room In-home assessment for an older adult client who is at risk for falls. Which of the following assessment findings should the nurse identify as a potential hazard? ANS: A comp. chair wheels In patient psychiatric unit is setting short-term goals for an adolescent who was admitted for tx of anorexia nervosa ANS: The client will develop personalized meal plan Involuntarily admitted to psychiatric unit following a failed suicide attempt - experimental tx ANS: Witness consent before medication administration Lab data on client who has dehydration ANS: Elevated BUN Lab values on a client who has taken an overdose of acetaminophen - organ damage ANS: ALT Mastitis of left breast - does this mean that i must stop nursing my baby? ANS: No, you can continue to nurse from both your breasts medical unit received change-of-shift report ... ANS: 68 yr old Morning lab values to several clients ... ANS: Client who is prescribed digoxin and furosemide