MEDSURG VATI ASSESSMENT WITH
COMPLETE SOLUTIONS VERIFIED 100%
A nurse examining a client's rhythm strips notices no visible P waves but many small,
erratic
spikes throughout the strip as well as variable ventricular rate. The nurse should identify
and
report this pattern as which of the following dysrhythmias?
- Atrial Fibrillation - ANSWER-- Atrial Fibrillation
The nurse should identify that during atrial fibrillation, the atrioventricular node cannot
respond to so many atrial impulses. Therefore, it sends impulses to the ventricles in an
erratic way, which accounts for these characteristics on the client's rhythm strip.
A nurse in a long term facility is delegating client care tasks to staff members. Which of
the following tasks should the nurse assign to an assistive personnel (AP)?
- Document a client's output for the shift - ANSWER-- Document a client's output for the
shift
A nurse is administering a tap water enema to a client who has constipation. The client
reports
abdominal cramping during instillation of the enema. Which of the following actions
should the
nurse take
- Slow the rate of fluid flow - ANSWER-- Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the intestinal spasm to
pass if cramping occurs during administration of the enema. Lowering the height of the
enema bag will decrease the rate the fluid enters the bowel. Tap water enemas consist
of 500 mL to 1 L of fluid that is instilled into the bowel to soften feces. The volume of
fluid stimulates peristalsis.
A nurse is assisting a client to move from a bed to a wheelchair. The client had a total
knee arthroplasty 2 days ago and reports generalized weakness. Which of the following
is an appropriate action by the nurse
-Place the wheelchair at 90 angle to the bed
- Lock the wheels of the bed and the wheelchair
- ask the client to place the foot of the eaker leg beneath the edge og the bed
_ Elevate the bed to position of comfort for the nurse - ANSWER-- Lock the wheels of
the bed and the wheelchair
The nurse should always keep the wheels of the bed and wheelchair in the locked
position to prevent them from moving when transferring a client.
,A nurse is assisting a client who has hypertension in making healthy dietary selections
regarding
sodium intake. Which of the following foods should the nurse instruct the client to avoid?
- Pretzels - ANSWER-- Pretzels
A nurse is assisting a client who is on bed rest to preform isometric exercises. Which of
the following actions should the nurse take
- Instruct the client to tighten and then relax muscles repeatedly - ANSWER-- Instruct
the client to tighten and then relax muscles repeatedly
The nurse should instruct the client to perform isometric exercises by holding muscles
tight for 5 seconds and then relaxing them. This form of exercise involves static
contraction of a muscle without any movement of the joint. Immobility can cause
systemic physiologic effects such as increased heart rate, increased bone
demineralization, decreased muscle strength, joint contractures, and activity
intolerance. Isometric exercises increase muscle mass, tone, and strength while
promoting circulation.
A nurse is assisting with the care of a client who has cellulitis and is receiving IV
Ceftriaxone.During data collection, the nurse notes the client is flushed and the client
reports urticarial. After stopping the IV infusion, which of the following actions should the
nurse take first?
-Check clients respiration - ANSWER-Check clients respiration
After stopping the IV infusion, the first action the nurse should take when using the
airway, breathing, circulation approach to client care is to count the client's respirations
and monitor for dyspnea because a client experiencing an allergic reaction can progress
to anaphylactic shock and death.
A nurse is assisting with the care of four clients. Which of the following clients is the
priority for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 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 - ANSWER-- A client who has chest
tubes and an oxygen Sat of 90%
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, which is below
the expected reference range of 95% to 100%. Therefore, the nurse should attend to
this client first.
, A nurse is caring for a client who has heart failure and a new prescription for
furosemide. The nurse should monitor the client for which of the following
manifestations as an adverse effect of
the medication.
- Tinnitus - ANSWER-- Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing loss.
Audiometry is recommended for clients receiving prolonged IV furosemide.
A nurse is caring for a client who has Phantom pain after healing from a below knee
amputation. which of the followingmedication should the nurse expect the provider to
prescribe to relieve the clients pain?
- Pregablin - ANSWER-Pregabalin
Pregabalin is an anticonvulsive medication that is an adjuvant medication for treating
neuropathic pain such as phantom limb pain. Typically, with this type of pain, analgesics
and opioids are ineffective.
A nurse is caring for a client who has type1 diabetes mellitus and has undergone a
below the knee amputation. Which of the following is the highest priority findings
- Skin flap of the residual limb is cool to the touch - ANSWER-- Skin flap of the residual
limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is that the skin flap of the residual limb is cool to the
touch. The nurse should immediately report this finding to the provider. The skin flap of
the residual limb should be warm to the touch, indicating adequate tissue perfusion.
A nurse is caring for a client who is preoperative and does not speak the same
language as the nurse. Which of the following actions should the nurse take
- Incorporate the use of the pictures as a tool of communication - ANSWER--
Incorporate the use of the pictures as a tool of communication
The nurse should use communication tools, such as a message board, cards, or
pictures, to assist the client in communicating her needs.
A nurse is caring for a client who is receiving peripheral IV therapy. The nurse notes
that the IV
site is red, warm, and painful to the touch. Which of the following actions should the
nurse take?
- Discontinue the IV and apply a warm, moist compress to the site - ANSWER--
Discontinue the IV and apply a warm, moist compress to the site
Complications of intravenous therapy involve inflammation of the vein, phlebitis, and
can include the presence of clots or thrombophlebitis. Manifestations of these
complications include pain at the IV site, along with redness and warmth. The nurse
COMPLETE SOLUTIONS VERIFIED 100%
A nurse examining a client's rhythm strips notices no visible P waves but many small,
erratic
spikes throughout the strip as well as variable ventricular rate. The nurse should identify
and
report this pattern as which of the following dysrhythmias?
- Atrial Fibrillation - ANSWER-- Atrial Fibrillation
The nurse should identify that during atrial fibrillation, the atrioventricular node cannot
respond to so many atrial impulses. Therefore, it sends impulses to the ventricles in an
erratic way, which accounts for these characteristics on the client's rhythm strip.
A nurse in a long term facility is delegating client care tasks to staff members. Which of
the following tasks should the nurse assign to an assistive personnel (AP)?
- Document a client's output for the shift - ANSWER-- Document a client's output for the
shift
A nurse is administering a tap water enema to a client who has constipation. The client
reports
abdominal cramping during instillation of the enema. Which of the following actions
should the
nurse take
- Slow the rate of fluid flow - ANSWER-- Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the intestinal spasm to
pass if cramping occurs during administration of the enema. Lowering the height of the
enema bag will decrease the rate the fluid enters the bowel. Tap water enemas consist
of 500 mL to 1 L of fluid that is instilled into the bowel to soften feces. The volume of
fluid stimulates peristalsis.
A nurse is assisting a client to move from a bed to a wheelchair. The client had a total
knee arthroplasty 2 days ago and reports generalized weakness. Which of the following
is an appropriate action by the nurse
-Place the wheelchair at 90 angle to the bed
- Lock the wheels of the bed and the wheelchair
- ask the client to place the foot of the eaker leg beneath the edge og the bed
_ Elevate the bed to position of comfort for the nurse - ANSWER-- Lock the wheels of
the bed and the wheelchair
The nurse should always keep the wheels of the bed and wheelchair in the locked
position to prevent them from moving when transferring a client.
,A nurse is assisting a client who has hypertension in making healthy dietary selections
regarding
sodium intake. Which of the following foods should the nurse instruct the client to avoid?
- Pretzels - ANSWER-- Pretzels
A nurse is assisting a client who is on bed rest to preform isometric exercises. Which of
the following actions should the nurse take
- Instruct the client to tighten and then relax muscles repeatedly - ANSWER-- Instruct
the client to tighten and then relax muscles repeatedly
The nurse should instruct the client to perform isometric exercises by holding muscles
tight for 5 seconds and then relaxing them. This form of exercise involves static
contraction of a muscle without any movement of the joint. Immobility can cause
systemic physiologic effects such as increased heart rate, increased bone
demineralization, decreased muscle strength, joint contractures, and activity
intolerance. Isometric exercises increase muscle mass, tone, and strength while
promoting circulation.
A nurse is assisting with the care of a client who has cellulitis and is receiving IV
Ceftriaxone.During data collection, the nurse notes the client is flushed and the client
reports urticarial. After stopping the IV infusion, which of the following actions should the
nurse take first?
-Check clients respiration - ANSWER-Check clients respiration
After stopping the IV infusion, the first action the nurse should take when using the
airway, breathing, circulation approach to client care is to count the client's respirations
and monitor for dyspnea because a client experiencing an allergic reaction can progress
to anaphylactic shock and death.
A nurse is assisting with the care of four clients. Which of the following clients is the
priority for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 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 - ANSWER-- A client who has chest
tubes and an oxygen Sat of 90%
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, which is below
the expected reference range of 95% to 100%. Therefore, the nurse should attend to
this client first.
, A nurse is caring for a client who has heart failure and a new prescription for
furosemide. The nurse should monitor the client for which of the following
manifestations as an adverse effect of
the medication.
- Tinnitus - ANSWER-- Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing loss.
Audiometry is recommended for clients receiving prolonged IV furosemide.
A nurse is caring for a client who has Phantom pain after healing from a below knee
amputation. which of the followingmedication should the nurse expect the provider to
prescribe to relieve the clients pain?
- Pregablin - ANSWER-Pregabalin
Pregabalin is an anticonvulsive medication that is an adjuvant medication for treating
neuropathic pain such as phantom limb pain. Typically, with this type of pain, analgesics
and opioids are ineffective.
A nurse is caring for a client who has type1 diabetes mellitus and has undergone a
below the knee amputation. Which of the following is the highest priority findings
- Skin flap of the residual limb is cool to the touch - ANSWER-- Skin flap of the residual
limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is that the skin flap of the residual limb is cool to the
touch. The nurse should immediately report this finding to the provider. The skin flap of
the residual limb should be warm to the touch, indicating adequate tissue perfusion.
A nurse is caring for a client who is preoperative and does not speak the same
language as the nurse. Which of the following actions should the nurse take
- Incorporate the use of the pictures as a tool of communication - ANSWER--
Incorporate the use of the pictures as a tool of communication
The nurse should use communication tools, such as a message board, cards, or
pictures, to assist the client in communicating her needs.
A nurse is caring for a client who is receiving peripheral IV therapy. The nurse notes
that the IV
site is red, warm, and painful to the touch. Which of the following actions should the
nurse take?
- Discontinue the IV and apply a warm, moist compress to the site - ANSWER--
Discontinue the IV and apply a warm, moist compress to the site
Complications of intravenous therapy involve inflammation of the vein, phlebitis, and
can include the presence of clots or thrombophlebitis. Manifestations of these
complications include pain at the IV site, along with redness and warmth. The nurse
