PN VATI Fundamentals 2020 questions and 100% correct answers
A nurse is collecting data from an older adult client. Which of the following findings is an
indication of infection?
Decreased pulse rate
Urinary retention
Change in mental status
Decreased respiratory rate - correct answer-Change in mental status. (such as confusion
and agitation, might be CM of infection in an older adult client); or an increased respiratory
rate; urinary incontinence and urgency, an increased pulse rate.
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?
a. release hand pressure before replacing the drainage plug.
b. wear surgical gloves when emptying the drainage device
c. wipe the port with soap and water before closing the drain
d. compress the bulb to reestablish constant low negative pressure. - correct answer-d
=>that will work as a closed suction to draw secretions into the bulb
(to wipe the port and plug with an alcohol wipe before closing the drain to decrease the risk
for contamination; wear clean gloves when emptying the drainage device to prevent
contamination of the surgical wound; to maintain hand pressure while replacing the
drainage plug to create negative pressure.)
a home health nurse is collecting data during a home visit with a client. Which of the
following findings places the client at risk for falls (SATA)
Clutter in living areas
grab bars in the bathroom
dim lighting in the entrance hall
bedroom on the second floor
Throw rugs on the floor - correct answer-Clutter in living areas (because the presence of
scattered furniture and objects on the floor)
A nurse is collecting data from an older adult client. Which of the following findings is an
indication of infection?
Decreased pulse rate
Urinary retention
Change in mental status
Decreased respiratory rate - correct answer-Change in mental status. (such as confusion
and agitation, might be CM of infection in an older adult client); or an increased respiratory
rate; urinary incontinence and urgency, an increased pulse rate.
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?
a. release hand pressure before replacing the drainage plug.
b. wear surgical gloves when emptying the drainage device
c. wipe the port with soap and water before closing the drain
d. compress the bulb to reestablish constant low negative pressure. - correct answer-d
=>that will work as a closed suction to draw secretions into the bulb
(to wipe the port and plug with an alcohol wipe before closing the drain to decrease the risk
for contamination; wear clean gloves when emptying the drainage device to prevent
contamination of the surgical wound; to maintain hand pressure while replacing the
drainage plug to create negative pressure.)
a home health nurse is collecting data during a home visit with a client. Which of the
following findings places the client at risk for falls (SATA)
Clutter in living areas
grab bars in the bathroom
dim lighting in the entrance hall
bedroom on the second floor
Throw rugs on the floor - correct answer-Clutter in living areas (because the presence of
scattered furniture and objects on the floor)
