RN VATI Fundamentals Assessment 70
answered solutions
RN VATI Fundamentals Assessment 70
answered solutions
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. - ANSWER-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.
To mix insulin from two vials in the same syringe, the nurse should first draw up a
volume of air equal to the volume of insulin from the intermediate-acting insulin vial. The
nurse should then inject the volume of air equal to the amount of insulin to withdraw
from the intermediate-acting insulin vial, making sure the needle does not touch the
insulin. Next, the nurse should inject the volume of air equal to the insulin dose from the
short-acting insulin vial. Then, the nurse should withdraw the prescribed amount of
insulin from the short-acting insulin vial. Lastly, the nurse should withdraw the
prescribed amount of insulin from the intermediate-acting insulin vial. The insulins are
now mixed and ready to administer.
A nurse is assessing a client who wears partial dentures and reports mouth pain. Which
of the following actions should the nurse take? - ANSWER-Advise the client to rinse
their mouth and dentures after each meal.
The nurse should advise the client to rinse their mouth and dentures after each meal to
remove food and particles and to promote healing of gums and oral mucosa.
The nurse should instruct the client to rinse their mouth four times each day with mild
rinses, such as normal saline or sodium bicarbonate solution. The nurse should inform
the client that mouthwashes containing alcohol dry the oral mucosa and can irritate
tissue.
The nurse should instruct the client to brush their remaining teeth with a soft toothbrush
at least twice each day to reduce the risk for gum abrasions.
The nurse should avoid using lemon-glycerin sponges because they can cause erosion
of the client's tooth enamel, dry the mucous membranes, and increase the client's
current discomfort.
,RN VATI Fundamentals Assessment 70
answered solutions
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? - ANSWER-Speech-language
pathologist
The nurse should recommend a referral for a client who has dysphagia to a speech-
language pathologist. Clients who have dysphagia have difficulty swallowing and are at
risk for aspiration. The speech-language pathologist can perform a swallow study to
determine the extent of the client's dysphagia and work with the client to develop new
swallowing techniques.
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) - ANSWER-- 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? - ANSWER-Previous treatments
The nurse should include previous treatments in the "background" portion of the SBAR
communication tool. Other information the nurse should include in the "background"
portion is the client's admission history, diagnosis, pertinent medical history, and code
status. The nurse should include physical findings in the "assessment" portion of the
SBAR communication tool. The nurse should include questions regarding client care in
the "recommendation" portion of the SBAR communication tool. The nurse should
include the client's present condition in the "situation" portion of the SBAR
communication tool.
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? - ANSWER-"I will
store oxygen tanks in an upright position"
This statement by the client indicates an understanding of the teaching. The nurse
should instruct the client to store oxygen tanks in an upright position in a holder to
prevent damage to the tank and injury to the client and the client's family. The nurse
should instruct the client to check the oxygen equipment at least once daily to determine
if it is set to the prescribed oxygen rate. The nurse should instruct the client to place the
, RN VATI Fundamentals Assessment 70
answered solutions
oxygen equipment 2.4 m (8 ft) from a heat source to prevent injury from accidental
combustion.
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? -
ANSWER-"It must me a very difficult time for you."
The nurse is using the therapeutic communication technique of verbalizing the implied.
This technique puts into words what the client has said indirectly and creates a more
positive nurse-client relationship.
A nurse is assessing a client's coping skills. Which of the following should the nurse
identify as an internal stressor? - ANSWER-Fear of medical test results
Fear of medical test results is an internal stressor that originates within the body and
mind of a client. Internal stressors are pressures that the client places upon themselves
and are often the most common causes of stress. These stressors often force clients to
deal with conflicting inner values and interactions with others. When a client manages
internal stressors, it enhances their ability to deal with external stressors.
A nurse is performing postmortem care for an older client who had just died. Which of
the following actions should the nurse take? - ANSWER-Identify the client using 2
identifiers
The nurse should identify the deceased client using two identifiers, such as name and
birth date, or name and account number, and then compare the identifiers to the
information in the client's medical records
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? - ANSWER-65 mL
A client who has an NG tube can receive numerous liquid medications, plus water to
flush the tube before and after medications. Over a 24-hr period, these liquids can
amount to a significant intake. The nurse should document them on the intake and
output record. A value of 65 mL accounts for 5 mL of medication and two 30-mL
flushes.
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?
- ANSWER-Determine how the client views the concept of family
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