A nurse in the emergency department is caring for a client who was in a motor vehicle crash

VATI RN Comprehensive Predictor

1.A community health nurse is evaluating eligibility for home assistance for a client who is

quadriplegic. Which of the following actions should the nurse perform first?

a.Determine the client's living situation.

b.Problem solved with the client.

c. Offer community resources to the client.

d.Assist the client with decision-making.

2.A nurse is discussing care with a newly licensed nurse for a client who practices Orthodox

Judaism. Which of the following meals suggestions by the newly licensed nurse indicates a need

for further teaching?

a.Chicken breast and boiled potatoes.

b. Carrot sticks and cottage cheese.

c.Grilled cheese an Apple sauce.

d.Roast beef and ice cream.

3.A nurse is preparing to auscultate a client apical pulse at the point of maximal impulse (PMI). the

nurse should place the diaphragm of the stethoscope at which of the following locations

a.Within the angle of Louis.

b.5th intercostal space at the left midclavicular line.

c.Second intercostal space to the right of the sternum.

d.Over the xyphoid process.

4.A nurse is caring for a client who is receiving a blood transfusion at 125 mL/hour and develops a

hemolytic reaction. Which of the following actions should the nurse perform?

a. Infuse 0.9% sodium chloride IV.

b.Administer an anti-pyretic.

c.Decrease the infusion rate to 75 mL/hour.

d.Place the client in a left lateral position

5.A nurse is planning care for a client who is prescribed a cane for ambulation. Which of the

following nursing actions should the nurse include in the plan of care?

a.Remind the client to place the cane on the unaffected side.

b.Adjust the length of the cane to equal the distance from the client's iliac crest to the floor.

c.Remove the rubber tip from the cane to enhance ambulation.

d.Place the King safely in the closet during naps and at bedtime.

6.Nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral

feedings at 65 mL/hour through a gastrostomy tube. Which of the following findings requires

immediate intervention by the nurse?

a.The gastric residual volume is 250 mL following two hours of infusion.

b.The client is lying in a supine position.

c.The infusion pump for administering continuous feeding is turned off.

d.Interior feeding bag and tubing are not dated.

7.A nurse is caring for a group of clients which of the following tasks is appropriate for the nurse to

delegate to the assistive personnel (AP)? (Select all that apply.)

a.change addressing for a client who has a stage three decubitus ulcer.

b.Measure I&O for a client who is receiving peritoneal dialysis.

c.Transfer client from bed to chair with mechanical lift.

d.Provide postmortem care on a client who experienced cardiac arrest.

e.Obtain a signed consent for a client for a screening colonoscopy.