VATI GREEN LIGHT COMPLETE EXAM
REVIEW WITH FULL SOLUTIONS
●● A client who has a diagnosis of complete placenta previa is admitted
to the labor and delivery suite at 36 weeks gestation with contractions 5
min in frequency and 1 min in duration. Which of the following actions
should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam
Answer: C. Prepare the client for a cesarean section
●● A charge nurse on a pediatric unit is making assignments for a float
nurse from the medical unit. Which of the following clients is
appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory
treatments
B. A 4-year-old client who has a Wilms tumor and is receiving
chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a
ventricular septal defect tomorrow
D. A 14-year-old client who is scheduled for discharge today following
placement of a Harrington rod
,Answer: A. A 10-year-old client who has pneumonia and is receiving
respiratory treatments
●● A nurse notices smoke coming from a client's room and discovers a
fire in the wastebasket. After moving the client to safety, which of the
following is the priority action?
A. Notify the facility operator.
B. Close the fire doors on the unit.
C. Turn off oxygen sources.
D. Put out the fire with the appropriate extinguisher.
Answer: A. Notify the facility operator.
●● A nurse is assessing an infant who has water intoxication. Which of
the following findings should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
Answer: A. Generalized edema
●● A nurse is discussing the z-track administration of hydroxyzine with
a newly licensed nurse. Which of the following statements indicates the
newly licensed nurse understands the purpose of the technique?
A. This technique prevents injury to the sciatic nerve
,B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
Answer: This technique decreases the risk of subcutaneous infiltration
●● A nurse is creating a plan of care for a client who has anorexia
nervosa. Which of the following interventions should the nurse include
in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes
Answer: C. Monitor the client for 1 hr after meals
●● A nurse is planning care for a child who has increased intracranial
pressure with a decrease in level of consciousness. Which of the
following interventions should the nurse include in the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs
Answer: B. Maintain the head at a midline position
, ●● 10. A nurse is assessing a client who has delirium due to a febrile
illness. Which of the following findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia
Answer: A. Hallucinations
●● A nurse is assessing a client who is receiving enteral feedings via a
gastrostomy tube. The nurse should identify that which of the following
findings indicates fluid overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses
Answer: D. Bounding pulses
●● A nurse is caring for a client following an open colectomy. Which of
the following findings places the client at risk for delayed wound
healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
REVIEW WITH FULL SOLUTIONS
●● A client who has a diagnosis of complete placenta previa is admitted
to the labor and delivery suite at 36 weeks gestation with contractions 5
min in frequency and 1 min in duration. Which of the following actions
should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam
Answer: C. Prepare the client for a cesarean section
●● A charge nurse on a pediatric unit is making assignments for a float
nurse from the medical unit. Which of the following clients is
appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory
treatments
B. A 4-year-old client who has a Wilms tumor and is receiving
chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a
ventricular septal defect tomorrow
D. A 14-year-old client who is scheduled for discharge today following
placement of a Harrington rod
,Answer: A. A 10-year-old client who has pneumonia and is receiving
respiratory treatments
●● A nurse notices smoke coming from a client's room and discovers a
fire in the wastebasket. After moving the client to safety, which of the
following is the priority action?
A. Notify the facility operator.
B. Close the fire doors on the unit.
C. Turn off oxygen sources.
D. Put out the fire with the appropriate extinguisher.
Answer: A. Notify the facility operator.
●● A nurse is assessing an infant who has water intoxication. Which of
the following findings should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
Answer: A. Generalized edema
●● A nurse is discussing the z-track administration of hydroxyzine with
a newly licensed nurse. Which of the following statements indicates the
newly licensed nurse understands the purpose of the technique?
A. This technique prevents injury to the sciatic nerve
,B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
Answer: This technique decreases the risk of subcutaneous infiltration
●● A nurse is creating a plan of care for a client who has anorexia
nervosa. Which of the following interventions should the nurse include
in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose mealtimes
Answer: C. Monitor the client for 1 hr after meals
●● A nurse is planning care for a child who has increased intracranial
pressure with a decrease in level of consciousness. Which of the
following interventions should the nurse include in the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs
Answer: B. Maintain the head at a midline position
, ●● 10. A nurse is assessing a client who has delirium due to a febrile
illness. Which of the following findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia
Answer: A. Hallucinations
●● A nurse is assessing a client who is receiving enteral feedings via a
gastrostomy tube. The nurse should identify that which of the following
findings indicates fluid overload?
A. Diminished bowel sounds
B. Bradycardia
C. Hypotension
D. Bounding pulses
Answer: D. Bounding pulses
●● A nurse is caring for a client following an open colectomy. Which of
the following findings places the client at risk for delayed wound
healing?
A. INR 1.1
B. Hyperemesis
C. HbA1c 5.6%
