COMPLETE VATI Greenlight STUDY SET
A nurse is caring for a client who had a partial laryngectomy and is receiving continuous
enteral feedings at 65
... [Show More] mL/hr through a gastrostomy tube. Which of the following findings
requires immediate intervention by the nurse?
The infusion pump for administering continuous feeding is turned off.
A nurse is assessing a client who has a magnesium level of 4.4 mEq/L. Which of the
following findings should the nurse expect?
Hypotension
A nurse is providing dietary teaching to a client who has an increased cholesterol level.
Which of the following foods should the nurse recommend?
Egg whites
A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following
actions should the nurse plan to take?
Use a designated stethoscope when caring for the toddler.
A nurse is assessing a client who has a chest tube following a thoracotomy. Which of
the following findings requires intervention by the nurse?
1 cm of water present in the water seal
A nurse is reviewing the medical history of a client who is taking garlic supplement. The
nurse should identify that which of the following findings is a contraindication for taking
this supplement?
The client takes aspirin daily.
A nurse is planning to provide community education about viral hepatitis. Which of the
following should the nurse plan to include in the teaching?
series of four hepatitis vaccines is recommended to prevent viral hepatitis.
A nurse is reviewing the history and physical of a client who has right ventricular heart
failure. Which of the following is an expected finding?
Elevated pulmonary artery pressure
A home health nurse is conducting an initial home visit for a client who has terminal
breast cancer. The client has two school-age children and a limited support system.
Which of the following is the priority nursing action?
Inform the client of available community resources.
A nurse is providing postoperative teaching to a client who has a newly-inserted
pacemaker. Which of the following statements by the client indicates that the teaching
has been effective?
"I will use my cell phone on the ear opposite of my pacemaker."
lOMoAR cPSD|35974536
A nurse is caring for a client who has heart failure and has started taking a loop diuretic.
Which of the following findings indicates the client is experiencing an adverse effect of
the medication?
Decreased reflexes
lOMoAR cPSD|35974536
A nurse is caring for a client who has neutropenia due to HIV. Which of the following
precautions should the nurse take while caring for this client?
Wear an N95 respirator.
A nurse manager is presenting information to the nursing staff regarding the appropriate
use of client restraints. Which of the following should the nurse include? (Select all that
apply.)
The nurse should pad the bony prominences. The nurse should remove the restraints
every 2 hr. The provider's prescription should include the
A nurse is providing discharge teaching about disease prevention to a client who has
active tuberculosis. Which of the following should the nurse include?
Educating the client how to cover nose and mouth with tissues when coughing
A nurse is caring for a client who reports difficulty falling asleep at night. Which of the
following actions should the nurse take?
Schedule routine care tasks during hours when the client is awake.
A nurse is preparing a client for surgery and has just administered the preoperative
injection. Which of the following actions should the nurse take?
Review deep breathing and coughing exercises.
A nurse suspects another nurse is chemically impaired during their shift. Which of the
following is an appropriate action for the nurse to take?
Report to the nurse manager.
A nurse in the recovery room is assessing a client who has a new chest tube. The nurse
finds that the water seal is no longer tidaling. The nurse should identify the finding as
resulting from which of the following?
The tubing may be kinked.
A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel
(AP). When admitting a client who is experiencing acute liver failure and who has
ascites and an NG tube, which of the following tasks is most appropriate for the nurse to
delegate to the LPN?
Measure the amount of gastric drainage every 2 hr.
A nurse is assessing an adult male client who has a BMI of 20. The nurse should
identify that the client's BMI falls within which of the following categories?
Healthy weight
A nurse is assessing a client who has a long arm cast. For which of the following
findings should the nurse monitor when assessing for acute compartment syndrome?
Change in mental status
A nurse is planning care for a newly admitted client. Which of the following interventions
should the nurse plan to take first? (Click on the "Exhibit" button for additional
information about the client. There are three tabs that contain separate categories of
data.)
Administer pain medication to the client.
lOMoAR cPSD|35974536
A community health nurse is performing a vision screening on a 4-month-old infant.
When shining a light source into the infant's visual field, which of the following is an
expected finding?
The infant closes their eyes.
A nurse is planning discharge teaching for a client who is scheduled to receive
intravenous infusions at home. Which of the following instructions should the nurse plan
to include?
Place the infusion pump cord against the baseboards.
A nurse is caring for a client who has just returned to the unit following a bronchoscopy.
Which of the following actions by the assistive personnel requires the nurse to
intervene?
Offers oral fluids to the client
A nurse is assessing an infant who has water intoxication. Which of the following
findings should the nurse expect?
Generalized edema
A nurse is caring for a client who is in labor and receiving electronic fetal monitoring.
The nurse is reviewing the monitor tracing and notes early decelerations. Which of the
following should the nurse expect?
Head compression
nurse in a pediatric unit is caring for a group of clients. For which of the following
diseases should the nurse implement droplet precautions?
Pertussis
A client asks the nurse if it is safe to take a glucosamine supplement. The nurse should
assess for which of the following potential contraindications?
Shellfish allergy
A nurse at the family planning clinic triages several clients over the phone. Which of the
following clients should the nurse instruct to come to the clinic?
A client who has started taking oral contraceptives and is experiencing bright red
vaginal breakthrough bleeding
A nurse is caring for a client who has a hearing impairment. When speaking to the
client, the nurse should incorporate which of the following communication methods?
Rephrase sentences the client does not understand.
A nurse in a mental health facility is interviewing a newly admitted client. Which of the
following actions should the nurse take when conducting the interview?
Lean in slightly when speaking to the client.
A nurse is caring for a group of clients. Which of the following clients should the nurse
assign to an assistive personnel?
A client who had a stroke 2 days ago and needs help toileting
lOMoAR cPSD|35974536
A nurse manager at a public health clinic is concerned about the rising number of
sexually transmitted infections in the community. The purpose of which of the following
is to generate new ideas to address the public health concern?
A brainstorming session with nurses
A nurse is providing teaching about preventing mastitis to a client who is postpartum
and breastfeeding her newborn. Which of the following instructions should the nurse
include?
"Try to have your baby empty your breasts with each feeding."
A nurse is preparing to insert an indwelling urinary catheter for a female client. Identify
the sequence of actions the nurse should take. (Move the steps into the box on the
right, placing them in the order of performance. Use all the steps.)
Apply sterile gloves and place cleansing balls in antiseptic solution. Attach prefilled
syringe to indwelling catheter inflation hub. Cleanse the meatus with the dominant hand
in a downward motion. Lubricate the catheter and place fenestrated drape over
perineum. Insert the catheter until a flow of urine begins.
A nurse is providing teaching to a client who is at 8 weeks of gestation and experiencing
episodes of nausea and vomiting. Which of the following instructions should the nurse
include?
Eat a dry carbohydrate before getting out of bed.
A nurse is caring for a client who is nulliparous and in the first stage of labor. The last
internal assessment revealed 100% cervical effacement with 5 cm of dilatation. At the
end of the last contraction, the nurse observes a large gush of fluid coming out of the
client's perineal area. Which of the following is a priority action by the nurse?
Check the FHR.
A nurse is assessing a client who was brought to the emergency department by his
adult child. The client has visible contusions on all four extremities. Which of the
following actions should the nurse take?
Report the incident to Adult Protective Services.
A nurse is caring for a client who is postpartum and has a new prescription for
methylergonovine for vaginal bleeding refractory to fundal massage and oxytocin. When
reviewing the client's medical history, the nurse should recognize which of the following
diagnoses as a contraindication to the administration of methylergonovine?
Hypertension
A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse
should recognize that the teaching has been effective when the client states,
"My stoma will drain liquid fluid continuously."
At the start of an evening shift on a cardiac unit, a licensed practical nurse brings the
nurse a list of client reports. Which of the following client reports should the nurse
assess first?
Indigestion [Show Less]