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VATI Fundamentals Post....VATI Fundamentals Post
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A nurse is caring for a client who asks the nurse to explain what advance directives are. Which of the following statements should the nurse make? A. "The health care proxy is a document that explains your wishes for care when you can no longer do so." B. "Be sure that your family agrees with your choices before preparing your advance directives." C. "The provider consults your living will in the event that you are unable to make health care decisions." D. "Be sure you know what you want to write in your advance directives, because you can't change them later." - correct answer C. "The provider consults your living will in the event that you are unable to make health care decisions." Living wills direct care when clients do not have the capacity to make decisions. The provider will review the client's living will and plan treatment according to the client's preferences. A health care proxy is a document that appoints another individual to make health care decisions for the client. Although the family is usually involved, along with the provider, in helping to decide a client's decisional capacity, no one else has to agree with the client's choices. The nurse should instruct the client that they can change their advanced directives at any time. A nurse provides a medical interpreter to convey discharge instructions to a client who speaks a different language than the nurse. This action is an example of which of the following ethical values? A. Advocacy B. Nonmaleficence C. Veracity D. Justice - correct answer A. Advocacy Advocacy is the ethical principle of supporting the client in every situation. The nurse supports this client by using a medical interpreter to ensure that the client
understands the discharge teaching. Nonmaleficence is a commitment to do no harm. Although this principle is essential to the practice of nursing, this action is not an example of nonmaleficence. Veracity is telling the truth. Although this principle is essential to the practice of nursing, this action is not an example of veracity. Justice is fairness in care delivery to all clients in order to ensure each client's needs are met. Although this principle is essential to the practice of nursing, this action is not an example of justice. A nurse is reviewing guidelines for documentation in an electronic medical record with a newly licensed nurse. Which of the following information should the nurse include? A. It is important to include personal opinions when documenting assessments. B. Wait until the end of the shift to document an error. C. It is acceptable to document for another nurse in urgent situations. D. Log out of the computer terminal after completing documentation. - correct answer D. Log out of the computer terminal after completing documentation. It is important for the nurse to maintain the security of clients' medical records. Without logging out, others could view or access clients' confidential health information. A nurse receives handoff report on several clients. Which of the following clients is the nurse's priority? A. A client who is postoperative following coronary artery bypass grafting and needs discharge teaching B. A client requiring education about a new prescription for treating asthma C. A client who has a decreased level of consciousness D. A client who is crying after receiving a terminal diagnosis - correct answer C. A client who has a decreased level of consciousness A client who has a decreased level of consciousness is unstable; therefore, this client is the nurse's priority and requires immediate action by the nurse.
and/or certification can insert subclavian central venous access devices. This task is beyond the scope of nursing practice. Nurses can insert peripherally inserted central catheters (PICCs) with specialized training. A nurse is performing a home safety assessment for a client who had a stroke. The nurse note that the stairs in the client's home are in disrepair and pose a safety risk. The client states, "I cannot afford to have the stairs repaired." Which of the following actions should the nurse take? A. Refer the client to a social worker. B. Provide the client with information about the American Red Cross. C. Ask the client's provider to postpone discharge until the stairs are repaired. D. Recommend a long-term care facility for the client. - correct answer A. Refer the client to a social worker. The nurse should refer the client to a social worker, who can assist a client who is having financial difficulties. The social worker can find resources to repair the stairs. The American Red Cross is a nonprofit organization that provides preparedness education and relief in the event of a disaster. There is no medical indication that warrants postponing the client's discharge. A long-term care facility is indicated for clients who are no longer able to perform their own activities of daily living. There is no indication that warrants recommending a long-term care facility for the client. A nurse is admitting a client who is at risk for falls. Which of the following interventions should the nurse include in the client's plan of care? A. Keep all four side rails in the up position. B. Offer assistance with toileting every 4 hr. C. Place the client's personal possessions in the bedside closet. D. Have the client demonstrate how to use the call light. - correct answer D. Have the client demonstrate how to use the call light.
The nurse should demonstrate use of the call light for the client and ask for a return demonstration to confirm the client's understanding. This ensures the client will be able to request assistance quickly and reduces the risk for falls. Evidence-based practice indicates that raised side rails can pose a safety hazard. Clients might still try to get out of bed by climbing over the rails, which can increase the risk of falling. The nurse should make rounds and offer the client assistance with elimination every hour from 0600 to 2200 and every 2 hr between 2200 and 0600 to decrease the incidence of falls. When an elimination need becomes urgent and the client does not have immediate assistance, a fall is possible when attempting to get out of bed. The nurse should place the client's personal possessions within easy reach to decrease the risk for falls. A nurse is preparing to move a client who is immobile up in bed with the assistance of another nurse. Which of the following actions should the nurse plan to take? A. Position the feet and knees close together. B. Tighten the back muscles when lifting. C. Keep the back, pelvis, feet, and neck in alignment. D. Bend at the waist when lifting. - correct answer C. Keep the back, pelvis, feet, and neck in alignment. To reduce the risk of injury to their lower back, the nurse should align their neck, back, pelvis, and feet when lifting an object or moving a client. When lifting an object or moving a client, the nurse should establish a broad base of support by keeping their feet apart. This helps to increase stability and maintain center of gravity. The nurse should tighten their abdominal muscles, not the muscles in their back, to reduce the risk of injury to their lower back. The nurse should bend at their knees, not at their waist, when lifting or moving a client. A nurse discovers a fire in a client's room in a wastebasket where some isopropyl alcohol was discarded. Which of the following types of fire extinguisher should the nurse use to put out the fire? A. A