PN FUNDAMENTALS VATI COMPLETE SOLUTION 2022.REAL DEAL

1.A nurse at a rehabilitation facility is assisting with the admission of a client who has lefthemiplegia following a stroke. Which of the following actions should the nurse take first? ANS:Determine the client's mental status2.A nurse is planning care for a client who practices Judaism. Which of the following questionsshould the nurse ask the client to better understand how he practices Judaism? ANS: "Do youobserve the Sabbath?"3.A nurse is caring for a client who has a visual impairment. When setting up the client's mealtray, the nurse should take which of the following actions? ANS: Describe food placementusing the numbers on the face of a clock4.A nurse is reinforcing teaching with a male client about clean intermittent self-catheterization.Which of the following instructions should the nurse include? ANS: Wash the catheter withsoap and water after use5.A nurse is caring for a client who has a terminal illness. Which of the following is an expectedresponse by a family member during the anger stage of grieving? ANS: The family membercriticizes care provided by the nurse6.A nurse is assisting with the plan of care for a client who is dying. Which of the followinginterventions should the nurse include in the plan of care? ANS: Allow family to assist theclient with personal hygiene7.A nurse is preparing to collect blood samples from an older adult client. Which of the followingactions should the nurse take when performing venipuncture? ANS: Apply the tourniquet overthe client's sleeve8.A nurse is collecting data from a client who is receiving a continuous IV infusion of lactatedRinger's for dehydration. Which of the following findings indicates infiltration of the solution intothe subcutaneous area? ANS: The area around the infusion site is cool to the touch9.A nurse is reinforcing teaching about home safety with a client who is at risk for falls. Which ofthe following client statements indicates an understanding of the teaching? ANS: I will secureall of my electrical cords to the baseboard10.A nurse is reinforcing teaching about sleep promotion with a client who reports having difficultysleeping. Which of the following client statements indicates an understanding of the teaching?ANS: I should play music that relaxes me before I go to bed11.A nurse is reinforcing teaching with the partner of a client who has left-sided weakness abouthow to safely move the client from a bed to a chair at home. which of the following statementsby the partner indicates an understanding of the teaching? ANS: I'll bend at the knees whenlifting to get better leverage 12.A nurse is reinforcing teaching about health promotion with an older adult client. Which of the following instructions to the client is an example of secondary prevention? ANS: Participate in screenings for tuberculosis 13.A nurse is monitoring an assistive personnel (AP) who is measuring a client's oxygen saturation using a pulse oximeter. Which of the following observations by the nurse indicates that the AP is correctly performing the task? ANS: The AP chooses a site with a capillary refill of less than 2 seconds. 14.A nurse is reviewing the laboratory results of a client who has malnutrition and has been receiving total parenteral nutrition (TPN). The nurse should identify that which of the following laboratory values indicates the treatment has been effective? ANS: Prealbumin 28 mg/dL 15.A nurse is preparing to perform wound irrigation for a client who has a stage IV pressure ulcer. Which of the following images indicates the appropriate supply the nurse should plan to use? ANS: Nurse should select a 30 to 60 mL syringe and use an 18 to 19 gauge needle to irrigate the client's wound. 16.A nurse is caring for a client who has vancomycin-resistant enterococci (VRE) in a wound. Which of the following actions should the nurse take to control the transmission of this infection? ANS: Wear a gown when assisting the client with hygiene care 17.A nurse is contributing to the plan of care for a client who follows a kosher diet. Which of the following dietary interventions should the nurse expect to include in the plan? ANS: Withhold foods that contain both meat and dairy products 18.A nurse is caring for a client who states that he is concerned that his neighbor, who works as an assistive personnel (AP) on another inpatient unit, will access his records and share his information with others. Which of the following is an appropriate response by the nurse? ANS: "only those who are involved with some aspect of your care may access your health care information" 19.A nurse is preparing to administer a medication intramuscularly to an adult client. Which of the following is the preferred site for administering the medication to this client? ANS: Ventrogluteal 20.A nurse is reinforcing discharge teaching about preventing thrombophlebitis with a client who is postoperative. Which of the following statements by the client indicates an understanding of the teaching? ANS: "I will do leg exercises every 1 to 2 hours while I am awake" 21.A nurse is reinforcing teaching about health promotion with a client. Which of the following actions should the nurse take first to promote effective learning? ANS: Identify areas of concern 22.A nurse is providing change-of-shift report for a client who had a stroke 48 hr ago. Which of the following information should the nurse include in the report? ANS: The client's Glasgow coma scale score ALL THE BEST 23.A nurse is caring for a client who has cancer and is asking about hospice care. Which of the following responses should the nurse make? ANS: The hospice staff's focus is to relieve your pain and distress 24.A nurse in a community center is reinforcing teaching about health risks with a group of adolescent clients. Which of the following topics is the priority for this age group? ANS: Driving while intoxicated 25.A nurse is caring for a client who is upset about receiving a terminal diagnosis. The client states, "I want some time alone to pray," Which of the following is an appropriate response by the nurse? ANS: How much time alone do you think you will need 26.A nurse is caring for a client who reports difficulty sleeping due to the noise on the nursing unit. Which of the following actions should the nurse take to reduce environmental noise? ANS: Close the door to the client's room 27.A nurse is collecting date from an older adult client. Which of the following findings is an indication of infection? ANS: Change in mental status 28.A nurse is reinforcing teaching about guided imagery with a client who has chronic pain. Which of the following information should the nurse include? ANS: This method uses the mind to create pictures to produce physical changes in the body 29.A nurse is assisting with the admission of a client who has varicella. Which of the following isolation precautions should the nurse implement? ANS: Place a surgical mask on the client during transport. 30.A nurse is caring for a client who is 1 day postoperative following an abdominal hysterectomy. The client states, "I am so sad that I can't have any more children." Which of the following is a therapeutic response by the nurse? ANS: "I will stay with you while we talk some more about this." 31.A nurse is reinforcing dietary teaching with a client who is receiving chemotherapy and has lost 6.8 kg (15 lb) since beginning therapy. Which of the following client statements indicates an understanding of the teaching?ANS: "I will replace water in recipes with whole milk" 32.A nurse is caring for a client who is postoperative following an above-the-knee amputation. The client tells the nurse he doesn't want to go to physical therapy and is "ready to give up." Which of the following responses should the nurse make? ANS: "You sound like you are feeling pretty discourage." 33.A nurse is reinforcing teaching with an older adult client about home safety. Which of the following instructions should the nurse include? ANS: Refrigerate foods within 2 hours after being at room temperature 34.A nurse is reviewing a client's laboratory results. Which of the following findings should the nurse report to the charge nurse as a manifestation of infection? ANS: Neutrophils 80% ALL THE BEST 35.A nurse is documenting client care in a client's medical record. The nurse should document which of the following notes as a subjective data? ANS: The client reports a mild burning pain on his buttocks 36.A nurse is assisting in the plan of care for a client who has a closed-wound drainage system. Which of the following interventions should the nurse include in the plan? ANS: Compress the bulb to re-establish constant low negative pressure 37.A nurse is assisting with the plan of care for an older adult client. When planning care, the nurse should consider that which on the following is a common physiological change that occurs with aging? ANS: Decreased subcutaneous fat 38.A nurse is reinforcing teaching with an assistive personnel (AP) about positioning a client who has GERD. Which of the following actions by the AP indicates an understanding of the teaching?ANS: The AP positions the foot of the client's bed lower than the head of the bed. 39.A nurse is reinforcing teaching with a client who has a new prescription for home oxygen therapy with an oxygen tank. Which of the following statements by the client indicates an understanding of the teaching? ANS: "I will replace my wool blanket with one made of cotton material." 40.A nurse is preparing to perform suctioning for a client who has a tracheostomy tube. Which of the following materials should the nurse obtain? ANS: Resuscitation bag 41.A nurse is assisting in the plan of care to prevent pressure ulcers for a client who is immobile. Which of the following interventions should the nurse include in the plan? ANS: Reposition the client at least every 2 hr. 42.A nurse is reinforcing teaching with a client who has a BMI of 27. Which of the following client statements indicates an understanding of the teaching? ANS: "I will increase my physical activity." 43.A nurse is preparing to administer an intermittent enteral feeding every 4 hr to a client who has an NG tube. Which of the following findings requires that the nurse withhold the feeding? ANS: Three episodes of diarrhea in the last 24 hr