RN VATI Fundamentals Practice

Question 1

RN VATI Fundamentals Practice. A nurse is caring for a client. Which of the following actions by the nurse indicate cultural competence? (Select the 3 actions that indicate cultural competence.)

Express interest in client’s culture.
Client teaching about medications.
Integrate religious beliefs with plan of care.
Implementation of suicide precautions.
Use of interpreter.

Case Study Summary: Question 2

The client is a 71-year-old with end-stage colon cancer who has transitioned to hospice and palliative care. They were admitted due to increasing difficulty with personal care and symptoms at home. Assessment findings include a high pain level (8/10), restlessness, grimacing, and a firm, distended abdomen.

Priority Action: Address pain.
Intervention: Administer a PRN dose of an opioid analgesic.

Case Study Summary: Question 3

The client’s condition changed between 1000 and 1400 hours. At 1000, the client was alert with clear lung sounds and a pain level of 3/10. By 1400, the client became restless and confused, developed crackles in the lung bases, and reported a pain level of 7/10.

Priority Action: Address respiratory status.
Intervention: Assist the client to use an incentive spirometer.

Case Study Summary: Question 4

The client is postoperative following an open cholecystectomy. Clinical data indicates a significant drop in blood pressure (from 122/80 to 88/54 mmHg) and an increase in heart rate (from 84/min to 112/min). The client is also experiencing increased abdominal pain and has a large amount of bright red blood on the surgical dressing.

Priority Action: Address circulation.
Intervention: Notify the provider.

Case Study Summary: Question 5

The client is postoperative and experiencing acute respiratory distress. Vital signs show a respiratory rate of 30/min and a critically low oxygen saturation of 82% on room air. The client is using accessory muscles to breathe and appears anxious.

Priority Action: Address respiratory status.
Intervention: Administer oxygen via nonrebreather mask.

Question 8

A nurse is caring for a client immediately following a thoracentesis. Which of the following actions should the nurse take?

Position the client on the unaffected side.
Maintain the head of the bed at 45°.
Measure the client’s abdominal girth at the level of the umbilicus.
Leave the puncture site open to air.

Question 9

A nurse is planning care for a group of clients. Which of the following clients should the nurse recognize is most at risk for social isolation?

An older adult client who began volunteering at a local clinic following their partner’s death
An adolescent client who reports spending more time with friends than close family
A client who is being discharged to a rehabilitation facility rather than home following surgery
A client who is terminally ill and whose family members are in denial of the impending death RN VATI Fundamentals Practice

Question 10

A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected clients who have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for which of the following clients?

A client who has chronic back pain and a history of physical maltreatment
A client who has chronic joint discomfort and a history of mild dementia
A client who has chronic knee pain and a history of grand mal seizures
A client who has chronic hip pain and a history of uterine cancer

Question 11

A nurse is caring for a client who is postoperative and has a PCA pump for pain management. The client states, “I have concerns about my pain pump.” Which of the following responses should the nurse make? RN VATI Fundamentals Practice

“You shouldn’t be concerned because the pump is very easy to use.”
“We can talk more about your worries regarding your pump if you’d like.”
“We use these pumps all the time after surgery, and they work great.”
“Your provider wouldn’t prescribe this pump if it wasn’t the best option for you.”

Question 12

A home health nurse is making an initial assessment visit to an adult client who has type 1 diabetes mellitus. Which of the following statements should the nurse make to evaluate the client’s ability to measure blood glucose accurately?

“Please use your glucometer and show me the results.”
“Please tell me how long you have been using this glucometer.”
“These blood glucose results you’ve written down do not seem correct.”
“Let me show you how to use this glucometer, so you can see if this is how you’ve been using it.”

Question 34

A nurse is teaching a parent about home safety for a child who is 2 years old. Which of the following instructions should the nurse include?

Place safety gates at the bottom of stairs.
Keep ammunition and guns in separate, locked locations.
Check the temperature of the child’s bath water with a hand.
Store toxic liquids in plastic containers.

Question 35

A nurse is preparing to administer heparin 2,000 units subcutaneously. The amount available is heparin 5,000 units/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.4 mL

Question 36

A nurse is assessing a client who has had no bowel movement for 3 days. Which of the following actions should the nurse take first?

Auscultate each of the four quadrants for 5 min before determining sounds are absent.
Perform a digital rectal examination.
Inquire if the client is passing flatus.
Palpate the abdomen for areas of tenderness.

Question 37

A nurse is performing a physical assessment of a client. Which of the following techniques should the nurse use to check for the presence of edema?

Use a skin calipers.
Use a reflex hammer.
Use a goniometer.
Use the pads of the fingers to apply pressure.

Question 38

A nurse is caring for a client who is at risk for falls. To which of the following locations should the nurse secure the client’s bed alarm?

Side rail
Headboard
Moveable portion of the bed frame
Footboard

Question 39

A nurse is planning care for a client who is at risk for developing a pressure injury. Which of the following interventions should the nurse include in the plan of care?

$30^{\circ}$ lateral
Position the client in a high-Fowler’s position.
Massage reddened areas of the skin.
Place the client on a ring-shaped cushion.

Question 40

A nurse is planning to move a client who is obese and has right-sided paralysis from a bed to a chair. Which of the following actions should the nurse take?

Use an air-assisted transfer device to move the client.
Keep feet close together when lifting the client.
Lift the client by placing arms under the client’s axillae.
Maintain a position at the client’s right side during the transfer.

Question 41

A nurse is providing oral hygiene for a client who has stomatitis. Which of the following actions should the nurse take?

Advise the client to rinse their mouth and dentures after each meal.
Apply a firm-bristled toothbrush to the teeth.
Use a lemon-glycerin swab to clean the gums.
Provide an alcohol-based mouthwash for the client to use.

Question 42 (Part A)

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. Which of the following actions should the nurse take?

Ensure the client’s feet are well supported by the floor.
Place the chair on the client’s weaker side.
Keep the bed in the highest position.
Hold the client by the arms to provide support.

Question 42 (Part B)

A nurse is reviewing the medical records of a group of clients. Which of the following clients should the nurse identify as being at risk for aspiration? RN VATI Fundamentals Practice

A client who has a history of gastroesophageal reflux disease
A client who consistently coughs after drinking liquids
A client who has a prescription for a clear liquid diet
A client who has chronic obstructive pulmonary disease

Question 43

A nurse is caring for a client who has a prescription for a vest restraint. Which of the following images indicates the correct location for the nurse to tie the restraint?

Question 44 (Part A)

A nurse is performing tracheostomy care for a client. Which of the following actions should the nurse take?

Apply suction for no more than 10 to 15 seconds.
Use a clean technique when performing tracheostomy care.
Apply suction while inserting the catheter into the tracheostomy. RN VATI Fundamentals Practice
Rinse the inner cannula with tap water.

Question 44 (Part B)

A nurse is caring for a client who has difficulty swallowing. To which of the following members of the interprofessional team should the nurse initiate a referral? RN VATI Fundamentals Practice

Physical therapist
Speech-language pathologist
Occupational therapist
Registered dietitian

Question 45

A nurse is preparing to administer ophthalmic drops to a client. Which of the following actions should the nurse take?

Hold the medication dropper 1 to 2 cm (0.4 to 0.8 in) above the conjunctival sac.
Apply the drops directly onto the cornea.
Ask the client to look down before instilling the drops.
Wipe the eye from the outer canthus to the inner canthus.

Question 46

A nurse is caring for a client who is 2 days postoperative following a bowel resection and reports a sudden increase in pain. Which of the following actions should the nurse take first?

Assess the client’s current level of pain.
Administer the prescribed PRN pain medication.
Reposition the client for comfort.
Check the client’s surgical incision site.

Question 47

A nurse is talking with the parent of a preschool-aged child who is hospitalized. The parent states, “I feel so guilty that I have to work while my child is here.” Which of the following responses should the nurse make?

“Your child is receiving excellent care while you are at work.”
“It’s common to feel this way when your child is in the hospital.“
“I’m sure your child understands that you have to work.”
“You should try to spend as much time as possible with your child.”

Question 48

A nurse is planning care for a client who has expressive aphasia. Which of the following interventions should the nurse include in the plan of care?

Provide the client with a picture board.
Speak to the client in a loud voice.
Avoid using nonverbal communication with the client.
Limit the time the client has to respond to questions.

Question 49

A nurse is teaching a client about how to collect a 24-hour urine specimen. Which of the following instructions should the nurse include?

Discard the first voiding.
Keep the specimen at room temperature.
Start the collection at a specific time of day.
Add a preservative to the specimen container.

Question 50

A nurse is preparing to administer an intramuscular injection to a client. At which of the following angles should the nurse plan to insert the needle?

15°
60°
45°
90°

Question 51

A nurse is evaluating preoperative teaching with a client who is to undergo surgery with general anesthesia. Which of the following statements by the client indicates an understanding of the teaching?

“I can leave my contact lenses in place during surgery.”
“I will pull my hair back with a hair clip before applying the surgical cap.”
“I should remove nail polish from my fingers before surgery.”
“I can keep my eye makeup on during surgery.”

Question 52

A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client’s surgery? (Select all that apply.)

Schedule the client as the last surgery of the day.
Notify ancillary departments of the client’s allergy.
Label the surgical suite as latex-free.
Provide powdered gloves for the staff’s use.
Ensure a latex allergy cart is available.

Question 53

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

Peer pressure
Death of a family member
Fear of medical test results
Job transfer to another city RN VATI Fundamentals Practice

Question 54

A charge nurse is providing an in-service about client advocacy to a group of newly licensed nurses. Which of the following examples should the nurse include?

Witnessing a client’s signature for informed consent
Instructing a client about how to apply antiembolic stockings
Ensuring that all clients receive equal treatment
Requesting a social services consultation for a client who states they cannot afford their medications

Question 55

A nurse is providing discharge teaching to a client about bathtub safety. Which of the following statements by the client indicates an understanding of the teaching?

“I will limit the length of my bath to 30 minutes.”
“I will apply bath oil to the water to moisturize my skin.”
“I will drain the tub after I get out.”
“I will place a bathmat in front of the tub.”

Question 59

A nurse is caring for an older adult client being admitted into a long-term care facility.

Nurses’ Notes 1000: 82-year-old client reports living alone for past 15 years until 6 months ago, when the client fell and moved in with their relative. Client states, “My family helps when they can, but they are really busy with work.”

1100: Client is oriented to person, place, and time. Notes 3 cm (1.18 inch) smooth, round nodule on the posterior scalp. Nodule reported as tender to palpation, hair fine, thin, gray, and unclean with pediculus humanus capitis noted. Skin dry with flaking, decreased skin turgor, multiple abrasions on bilateral arms and knees, scattered areas of ecchymosis in various stages of healing on arms, hips, knees, and buttocks. Nails long and unclean. Body odor with strong urine smell in underclothes. Gait unsteady and reports dizziness with standing.

Vital Signs 1030: Temperature 37.3°C (99.2°F) Heart rate 76/min Respiratory rate 20/min Blood pressure 148/90 mm Hg

Complete the following sentence by using the list of options.

The nurse should address the client’s [Select…] followed by [Select…].

risk of falls
hygiene
safety
trim nails
determine range of motion
notify Adult Protective Services

Question 60

A nurse on a medical-surgical unit is caring for a client.

Nurses’ Notes Day 2, 0800: Client’s right arm is casted and elevated on two pillows. Client is awake and oriented to person, place, and time. Left pupil is round and reactive to light and accommodation. Unable to assess pupil in right eye. Right eyelid is swollen shut. Fingers are slightly cool to touch, edematous, capillary refill is 5 seconds, and client is able to wiggle their fingers but not their thumb. Client reports occasional paresthesia of the right fingers. Unable to assess right radial pulse due to cast. Bruises noted on the right rib cage and in the right flank area. Large contusion across the right frontal and right temporal bone. Right eye lid is swollen shut and bruised. Breath sounds are clear and unlabored bilaterally. Respirations are shallow. Client reports not doing their deep breathing exercises and use of incentive spirometer due to rib pain. Breath sounds are decreased in the bases bilaterally and there are scattered crackles in the upper lobes. Client reports arm pain as a 9, right sided rib cage pain as an 8, and right eye and head pain as a 5 on a pain scale of 0 to 10.

The nurse assessed the client at 0800 on day 2. Which of the following findings indicate the client’s condition is worsening? Select all that apply.

Respiratory assessment
Temperature
Fluid balance
Neurological assessment
Neurovascular assessment

RN VATI Fundamentals Practice

Isaura K

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