Question

A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

Answer 1

Correct Answers:

Encourage fluid intake of 2,500 mL/day

Rationale :

🎯Fever increases insensible fluid losses through sweating and rapid breathing, which can lead to dehydration and electrolyte imbalances.

🎯Encouraging a fluid intake of 2,500 mL/day supports thermoregulation, promotes renal clearance of toxins, and helps thin respiratory secretions, making them easier to expectorate.

🎯Adequate hydration also enhances circulatory volume and tissue perfusion, which are critical in combating infection.

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Answer 2

Correct Answers:

Trace the size of stoma onto the skin barrier

Rationale :

⏺Proper fitting of an ostomy appliance involves accurately tracing the stoma's size and shape onto the skin barrier wafer.

⏺This ensures a snug fit around the stoma, protecting the peristomal skin from exposure to enzymatic effluent, which can cause irritation, breakdown, or infection.

⏺The opening should be no more than 1/8 inch larger than the stoma, ensuring secure adhesion and minimizing leakage.

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Answer 3

Correct Answers:

Encourage the family member to contact the client directly for information.

Rationale :

👌According to HIPAA regulations, nurses must maintain strict client confidentiality.

👌Disclosing medical information over the phone without verified client authorization violates this principle.

👌The nurse should politely redirect the caller to contact the client personally or obtain permission from the client to speak with designated individuals.

👌This action preserves both privacy rights and professional boundaries.

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Answer 4

Correct Answers:

Wear a surgical mask when within 0.9 m (3 feet) of the client.

Rationale :

📌Rubella is transmitted via large respiratory droplets, which can spread through coughing, sneezing, or talking within close proximity.

📌The nurse must implement droplet precautions, including the use of a surgical mask within 3 feet (0.9 m) of the client.

📌This protects both the nurse and other clients from potential exposure and aligns with CDC-recommended infection control guidelines for droplet-spread illnesses.

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Answer 5

Correct Answers:

Prepare the client for emergency surgery.

Rationale :

🟣Evisceration is the protrusion of abdominal organs through a surgical wound, often occurring after dehiscence.

🟣This is a life-threatening emergency requiring immediate surgical repair.

🟣After applying a sterile saline-moistened dressing to maintain tissue moisture and protect against infection, the nurse must notify the surgical team and prepare the client for an urgent return to the operating room.

🟣Vital signs monitoring, NPO status, and IV access should be maintained.

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Answer 6

Correct Answers:

Fear of medical test results.

Rationale :

Internal stressors arise from within the individual, involving personal fears, emotions, and perceptions.
Fear of medical test results reflects an emotional response tied to the anticipation of illness, diagnosis, or poor outcomes.
Unlike external stressors that involve environmental or situational pressures, internal stressors are often subjective and contribute significantly to psychological and physiological stress reactions.

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Answer 7

Correct Answers:

Previous treatments.

Rationale :

👉In the SBAR communication format, the Background section provides relevant client history, including diagnosis, hospital course, prior treatments, and responses to therapy.

👉This context helps the provider understand the clinical trajectory and ensures that the assessment and recommendation are interpreted accurately.

👉Accurate background information improves the clarity and continuity of care, especially in acute or evolving conditions.

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Answer 8

Correct Answers:

1 cup cantaloupe.

Rationale :

🔴Furosemide, a loop diuretic, causes significant potassium loss through the kidneys, leading to risks of hypokalemia, which can cause muscle weakness, fatigue, arrhythmias, and cardiac complications.

🔴Cantaloupe is a potassium-rich fruit and serves as a dietary measure to replenish serum potassium levels.

🔴Nurses must reinforce the importance of potassium-rich foods in clients on potassium-wasting medications.

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Answer 9

Correct Answers:

When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Rationale :

📌Using scissors near an intravenous catheter creates a severe safety hazard. 📌The catheter or skin could be accidentally cut, leading to bleeding, infection, or catheter embolism if the tip breaks off into circulation. 📌Nurses must remove tape manually and gently withdraw the catheter with the site stabilized. 📌Any sharp objects must be avoided during catheter removal. 📌This unsafe practice demands immediate correction.

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Answer 10

Correct Answers:

Teach the most crucial content early in the session.

Rationale :

✍Adult learners are typically goal-oriented, self-directed, and prefer immediate application of knowledge. ✍Teaching the most important and clinically relevant content first ensures that essential learning occurs when attention is highest. ✍This strategy respects adults' limited learning windows and promotes retention. ✍It also prepares learners to handle urgent or high-risk scenarios effectively after the session.

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RN VATI Fundamentals S 2019 FINAL

No.

1 :
A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

2 :
A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

3 :
A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

4 :
A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?

5 :
A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

6 :
A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?

7 :
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 Situation, Background, Assessment, Recommendation (SBAR) Communication tool?

8 :
A nurse is providing discharge teaching to a client who has heart failure and a new prescription for furosemide. Which of the following foods should the nurse recommend to the client as the best source of potassium?

9 : A nurse is observing a newly licensed nurse provide client care. Which of the following actions by the newly licensed nurse requires intervention by the nurse?

10 : A nurse is planning a community education session about the basic principles of first aid. Which of the following teaching strategies should the nurse implement for a group of adult learners in a community setting?

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RN VATI Fundamentals S 2019 FINAL

No.

1 : A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

2 : A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

3 : A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

4 : A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?

5 : A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

6 : A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?

7 : 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 Situation, Background, Assessment, Recommendation (SBAR) Communication tool?

8 : A nurse is providing discharge teaching to a client who has heart failure and a new prescription for furosemide. Which of the following foods should the nurse recommend to the client as the best source of potassium?

9 : A nurse is observing a newly licensed nurse provide client care. Which of the following actions by the newly licensed nurse requires intervention by the nurse?

10 : A nurse is planning a community education session about the basic principles of first aid. Which of the following teaching strategies should the nurse implement for a group of adult learners in a community setting?

1 :
A nurse is planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

2 :
A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

3 :
A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

4 :
A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?

5 :
A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

6 :
A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?

7 :
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 Situation, Background, Assessment, Recommendation (SBAR) Communication tool?

8 :
A nurse is providing discharge teaching to a client who has heart failure and a new prescription for furosemide. Which of the following foods should the nurse recommend to the client as the best source of potassium?