VATI Fundamentals Post-Assessment Exam V3 | Fundamentals of
Nursing (VATI Fundamentals Post-Assessment Exam) | Chamberlain
1. A nurse is preparing to administer an injection to a client. Which of the following actions
should the nurse take to prevent a needlestick injury?
A. Recap the needle using two hands after the injection.
B. Leave the needle on the bedside table for later pickup.
C. Bend the needle before disposal to ensure it cannot be reused.
D. Place the needle in a puncture-resistant container immediately.
Answer: D
Rationale: Discarding needles immediately into a puncture-resistant sharps container is
the primary method to prevent accidental needlestick injuries. Recapping needles,
especially with two hands, significantly increases the risk of a stick. Bending or breaking
needles is unsafe as it brings the hands too close to the sharp point and may create
aerosols.
2. A nurse is performing a physical assessment of an older adult. Which of the following
findings should the nurse identify as a normal age-related change?
A. Reduced sensitivity to high-pitched sounds.
B. Increased skin elasticity and turgor.
C. Increased cardiac output during exercise.
D. Heightened sense of taste and smell.
Answer: A
Rationale: Presbycusis, which is the loss of sensitivity to high-pitched sounds, is a common
age-related change in the sensory system. Older adults typically experience decreased skin
elasticity due to a loss of collagen and subcutaneous fat. Cardiac output and the ability to
taste or smell generally decrease rather than increase with advancing age.
3. A nurse is caring for a client who is on a clear liquid diet. Which of the following food items
should the nurse provide?
A. Vanilla pudding
B. Chicken broth
C. Orange juice with pulp
D. Sherbet
,Answer: B
Rationale: Chicken broth is considered a clear liquid because it is transparent and liquid at
room temperature. Vanilla pudding and sherbet are part of a full liquid diet as they contain
dairy or are opaque. Orange juice with pulp is not clear; only strained juices without pulp
are allowed on a clear liquid diet.
4. A nurse is teaching a client about a high-fiber diet. Which of the following food choices by
the client indicates an understanding of the teaching?
A. White bread and white rice
B. Peeled apples and fruit juice
C. Black beans and whole-grain crackers
D. Canned peaches and refined cereal
Answer: C
Rationale: Legumes like black beans and whole-grain products are excellent sources of
dietary fiber. Refined grains, such as white bread and white rice, have the fiber-rich bran
removed during processing. Peeling fruits and consuming juice rather than whole fruits
also reduces the total fiber intake.
5. A nurse is documenting in a client’s medical record. Which of the following entries is an
example of objective data?
A. ‘The client reports feeling nauseated.’
B. ‘The client appears to be in moderate pain.’
C. ‘The client states, I am worried about my surgery.’
D. ‘The client’s skin is warm and dry to the touch.’
Answer: D
Rationale: Objective data consists of observable and measurable information, such as skin
temperature and moisture. Statements made by the client regarding feelings or symptoms
are subjective data. Phrases like ‘appears to be’ are interpretations rather than factual
observations.
6. A nurse is caring for a client who is immobile. Which of the following actions should the
nurse take to prevent foot drop?
A. Place a pillow under the client’s knees.
B. Support the feet with padded splints or footboards.
C. Perform passive range-of-motion exercises once daily.
D. Position the client in the prone position for 4 hours.
, Answer: B
Rationale: Using footboards or splints maintains the feet in a dorsiflexed position, which
prevents the shortening of the calf muscles that causes foot drop. Pillows under the knees
can actually impede circulation and increase the risk of deep vein thrombosis. Range-of-
motion exercises should be performed more than once a day to be effective in preventing
contractures.
7. A nurse is assessing a client’s radial pulse and notes an irregular rhythm. Which of the
following actions should the nurse take?
A. Document the finding and reassess in 4 hours.
B. Notify the provider immediately of a medical emergency.
C. Check the pulse in the other arm for comparison.
D. Assess the apical pulse for one full minute.
Answer: D
Rationale: When a radial pulse is irregular, the nurse should assess the apical pulse for 60
seconds to obtain the most accurate heart rate and rhythm. This helps determine the
presence of a pulse deficit. Simply documenting and waiting does not address the current
clinical need for an accurate assessment.
8. A nurse is preparing to administer an enteral feeding through a nasogastric tube. Which of
the following actions should the nurse take first?
A. Verify the placement of the tube via X-ray report.
B. Aspirate gastric contents to check the pH.
C. Flush the tube with 30 mL of warm water.
D. Warm the formula to body temperature.
Answer: A
Rationale: Radiographic verification is the gold standard for confirming the initial
placement of a nasogastric tube. Once initial placement is confirmed, pH testing of aspirate
is used for ongoing verification. Flushing the tube or warming the formula occurs after the
nurse is certain the tube is in the stomach.
9. A nurse is using the SBAR communication tool to report a change in a client’s condition to a
provider. Which of the following statements should the nurse include in the ‘A’ (Assessment)
portion?
A. ‘I am calling about Mr. Smith in room 402 who is experiencing shortness of breath.’
B. ‘The client’s heart rate is 110 beats per minute and blood pressure is 90/60 mmHg.’
C. ‘The client has a history of congestive heart failure and was admitted yesterday.’
Nursing (VATI Fundamentals Post-Assessment Exam) | Chamberlain
1. A nurse is preparing to administer an injection to a client. Which of the following actions
should the nurse take to prevent a needlestick injury?
A. Recap the needle using two hands after the injection.
B. Leave the needle on the bedside table for later pickup.
C. Bend the needle before disposal to ensure it cannot be reused.
D. Place the needle in a puncture-resistant container immediately.
Answer: D
Rationale: Discarding needles immediately into a puncture-resistant sharps container is
the primary method to prevent accidental needlestick injuries. Recapping needles,
especially with two hands, significantly increases the risk of a stick. Bending or breaking
needles is unsafe as it brings the hands too close to the sharp point and may create
aerosols.
2. A nurse is performing a physical assessment of an older adult. Which of the following
findings should the nurse identify as a normal age-related change?
A. Reduced sensitivity to high-pitched sounds.
B. Increased skin elasticity and turgor.
C. Increased cardiac output during exercise.
D. Heightened sense of taste and smell.
Answer: A
Rationale: Presbycusis, which is the loss of sensitivity to high-pitched sounds, is a common
age-related change in the sensory system. Older adults typically experience decreased skin
elasticity due to a loss of collagen and subcutaneous fat. Cardiac output and the ability to
taste or smell generally decrease rather than increase with advancing age.
3. A nurse is caring for a client who is on a clear liquid diet. Which of the following food items
should the nurse provide?
A. Vanilla pudding
B. Chicken broth
C. Orange juice with pulp
D. Sherbet
,Answer: B
Rationale: Chicken broth is considered a clear liquid because it is transparent and liquid at
room temperature. Vanilla pudding and sherbet are part of a full liquid diet as they contain
dairy or are opaque. Orange juice with pulp is not clear; only strained juices without pulp
are allowed on a clear liquid diet.
4. A nurse is teaching a client about a high-fiber diet. Which of the following food choices by
the client indicates an understanding of the teaching?
A. White bread and white rice
B. Peeled apples and fruit juice
C. Black beans and whole-grain crackers
D. Canned peaches and refined cereal
Answer: C
Rationale: Legumes like black beans and whole-grain products are excellent sources of
dietary fiber. Refined grains, such as white bread and white rice, have the fiber-rich bran
removed during processing. Peeling fruits and consuming juice rather than whole fruits
also reduces the total fiber intake.
5. A nurse is documenting in a client’s medical record. Which of the following entries is an
example of objective data?
A. ‘The client reports feeling nauseated.’
B. ‘The client appears to be in moderate pain.’
C. ‘The client states, I am worried about my surgery.’
D. ‘The client’s skin is warm and dry to the touch.’
Answer: D
Rationale: Objective data consists of observable and measurable information, such as skin
temperature and moisture. Statements made by the client regarding feelings or symptoms
are subjective data. Phrases like ‘appears to be’ are interpretations rather than factual
observations.
6. A nurse is caring for a client who is immobile. Which of the following actions should the
nurse take to prevent foot drop?
A. Place a pillow under the client’s knees.
B. Support the feet with padded splints or footboards.
C. Perform passive range-of-motion exercises once daily.
D. Position the client in the prone position for 4 hours.
, Answer: B
Rationale: Using footboards or splints maintains the feet in a dorsiflexed position, which
prevents the shortening of the calf muscles that causes foot drop. Pillows under the knees
can actually impede circulation and increase the risk of deep vein thrombosis. Range-of-
motion exercises should be performed more than once a day to be effective in preventing
contractures.
7. A nurse is assessing a client’s radial pulse and notes an irregular rhythm. Which of the
following actions should the nurse take?
A. Document the finding and reassess in 4 hours.
B. Notify the provider immediately of a medical emergency.
C. Check the pulse in the other arm for comparison.
D. Assess the apical pulse for one full minute.
Answer: D
Rationale: When a radial pulse is irregular, the nurse should assess the apical pulse for 60
seconds to obtain the most accurate heart rate and rhythm. This helps determine the
presence of a pulse deficit. Simply documenting and waiting does not address the current
clinical need for an accurate assessment.
8. A nurse is preparing to administer an enteral feeding through a nasogastric tube. Which of
the following actions should the nurse take first?
A. Verify the placement of the tube via X-ray report.
B. Aspirate gastric contents to check the pH.
C. Flush the tube with 30 mL of warm water.
D. Warm the formula to body temperature.
Answer: A
Rationale: Radiographic verification is the gold standard for confirming the initial
placement of a nasogastric tube. Once initial placement is confirmed, pH testing of aspirate
is used for ongoing verification. Flushing the tube or warming the formula occurs after the
nurse is certain the tube is in the stomach.
9. A nurse is using the SBAR communication tool to report a change in a client’s condition to a
provider. Which of the following statements should the nurse include in the ‘A’ (Assessment)
portion?
A. ‘I am calling about Mr. Smith in room 402 who is experiencing shortness of breath.’
B. ‘The client’s heart rate is 110 beats per minute and blood pressure is 90/60 mmHg.’
C. ‘The client has a history of congestive heart failure and was admitted yesterday.’
