RN VATI Fundamentals 2019 Assessment,
Verified solution 100%
A nurse is preparing to mix short-acting and intermediate-acting insulin in one
syringe to administer to a client who has type 1 diabetes mellitus. Identify the
sequence the nurse should follow.
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.
A nurse is assessing a client who wears partial dentures and reports mouth pain.
Which of the following actions should the nurse take?
Advise the client to rinse their mouth and dentures after each meal.
A nurse is planning care for a client who has dysphagia and is at risk for
aspiration. Which of the following referrals should the nurse make?
Speech-language pathologist
thoracentesis post procedure?
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.
A nurse is planning teaching for a client who has a new diagnosis of type 2
diabetes mellitus. Which of the following actions should the nurse take prior to
performing the teaching? (select all that apply)
- 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
, A nurse is preparing to notify the provider about a change in a client's status.
Which of the following information should the nurse plan to include in the
"background" portion of the SBAR communication tool?
Previous treatments
A nurse is providing discharge teaching to a client who has a new prescription
for home oxygen therapy utilizing a compressed oxygen system. Which of the
following statements by the client indicates an understanding of the teaching?
"I will store oxygen tanks in an upright position"
A nurse is caring for a client who has terminal cancer. The client begins to cry
and says, "I am afraid of dying." Which of the following responses should the
nurse make?
"It must me a very difficult time for you."
A nurse is assessing a client's coping skills. Which of the following should the
nurse identify as an internal stressor?
Fear of medical test results
A nurse is performing postmortem care for an older client who had just died.
Which of the following actions should the nurse take?
Identify the client using two identifiers
A nurse has administered 5 mL of medication to a client via NG tube. Then used
30 mL of water to flush the tue both before and after the instillation. the nurse
should document which of the following amounts as liquid intake for the client?
65 mL
A nurse is performing a family assessment for a client who has recently
developed paraplegia following a stroke. Which of the following actions should
the nurse take first?
Determine how the client views the concept of family
A nurse is caring for a client who reports having insomnia due to increased
stress. Which of the following actions should the nurse take first?
Determine the source of the client's stress
A nurse is caring for a client who had a stroke and is immobile. Which of the
following actions should the nurse take to maintain the client's skin integrity?
Use an alcohol-free barrier product
A nurse receives a telephone prescription form the provider, who states, "four
milligrams of morphine diluted with 5 milliliters of sterile water intravenous each
morning at nine o'clock before client dressing changes." Which of the following
entries by the nurse indicates correct transcription of the prescription?
Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute medication with 5
mL of sterile water
how to assess for clonus?
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
Verified solution 100%
A nurse is preparing to mix short-acting and intermediate-acting insulin in one
syringe to administer to a client who has type 1 diabetes mellitus. Identify the
sequence the nurse should follow.
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.
A nurse is assessing a client who wears partial dentures and reports mouth pain.
Which of the following actions should the nurse take?
Advise the client to rinse their mouth and dentures after each meal.
A nurse is planning care for a client who has dysphagia and is at risk for
aspiration. Which of the following referrals should the nurse make?
Speech-language pathologist
thoracentesis post procedure?
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.
A nurse is planning teaching for a client who has a new diagnosis of type 2
diabetes mellitus. Which of the following actions should the nurse take prior to
performing the teaching? (select all that apply)
- 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
, A nurse is preparing to notify the provider about a change in a client's status.
Which of the following information should the nurse plan to include in the
"background" portion of the SBAR communication tool?
Previous treatments
A nurse is providing discharge teaching to a client who has a new prescription
for home oxygen therapy utilizing a compressed oxygen system. Which of the
following statements by the client indicates an understanding of the teaching?
"I will store oxygen tanks in an upright position"
A nurse is caring for a client who has terminal cancer. The client begins to cry
and says, "I am afraid of dying." Which of the following responses should the
nurse make?
"It must me a very difficult time for you."
A nurse is assessing a client's coping skills. Which of the following should the
nurse identify as an internal stressor?
Fear of medical test results
A nurse is performing postmortem care for an older client who had just died.
Which of the following actions should the nurse take?
Identify the client using two identifiers
A nurse has administered 5 mL of medication to a client via NG tube. Then used
30 mL of water to flush the tue both before and after the instillation. the nurse
should document which of the following amounts as liquid intake for the client?
65 mL
A nurse is performing a family assessment for a client who has recently
developed paraplegia following a stroke. Which of the following actions should
the nurse take first?
Determine how the client views the concept of family
A nurse is caring for a client who reports having insomnia due to increased
stress. Which of the following actions should the nurse take first?
Determine the source of the client's stress
A nurse is caring for a client who had a stroke and is immobile. Which of the
following actions should the nurse take to maintain the client's skin integrity?
Use an alcohol-free barrier product
A nurse receives a telephone prescription form the provider, who states, "four
milligrams of morphine diluted with 5 milliliters of sterile water intravenous each
morning at nine o'clock before client dressing changes." Which of the following
entries by the nurse indicates correct transcription of the prescription?
Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute medication with 5
mL of sterile water
how to assess for clonus?
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
