Recent Rn Vati Comprehensive Assmt Real
Exam 180 Questions And 100% Correct
Answers Recently Updated
SECTION I: MANAGEMENT OF CARE
1. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with COPD reporting shortness of breath, O2 saturation 88%
B. A client 2 days post-op requesting pain medication
C. A client with diabetes asking about diet
D. A client awaiting discharge instructions
Correct Answer: A
Rationale: Airway, Breathing, Circulation (ABC) priorities take precedence. An O2 saturation
of 88% in a COPD client indicates inadequate oxygenation requiring immediate assessment .
Pain management, education, and discharge planning are lower priorities when respiratory
compromise is present.
2. A competent adult client refuses a blood transfusion. Which action should the nurse take?
A. Administer the blood anyway
B. Notify the provider and document the refusal
C. Ask the family to convince the client
D. Restrain the client
Correct Answer: B
Rationale: A competent adult has the right to refuse treatment under the principle of
autonomy. The nurse must respect the refusal, notify the provider, and document the client's
decision . Administering treatment against the client's wishes constitutes battery.
3. Which task is appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Administering oral medications
B. Assessing a new admission
,C. Obtaining vital signs on a stable client
D. Teaching a client about insulin
Correct Answer: C
Rationale: UAPs can perform routine, stable tasks such as vital signs on stable clients .
Medication administration, assessment, and teaching require an RN license and clinical
judgment.
4. A nurse is triaging after a mass casualty event. Which client receives a RED tag?
A. Client with open femur fracture and weak pedal pulse
B. Client with massive head trauma and no respirations
C. Client with a sprained ankle
D. Client with minor lacerations
Correct Answer: A
Rationale: Red (Immediate) tag indicates life-threatening but survivable injuries requiring
rapid intervention. The femur fracture with weak pulse indicates vascular compromise . Black
tag is for clients with no respirations after repositioning.
5. A nurse is caring for a client who has a new diagnosis of terminal cancer. The client states,
"I don't want any more treatments." Which response demonstrates advocacy?
A. "You should discuss this with your oncologist before making any decisions."
B. "I will make sure your healthcare team knows your wishes and supports your decision."
C. "Let's wait until your family arrives so they can help you decide."
D. "I think you should reconsider because there are still treatment options available."
Correct Answer: B
Rationale: Advocacy means supporting the client's right to make informed decisions about
their own care . The nurse's role is to communicate the client's wishes to the healthcare team
and ensure they are respected, not to persuade or delay the client's decision.
6. A nurse is preparing to administer a blood transfusion. Which action is the highest priority
before initiating the transfusion?
,A. Obtain baseline vital signs
B. Prime the IV tubing with 0.9% sodium chloride
C. Verify the client's identity and blood product with another nurse
D. Assess the client's lung sounds
Correct Answer: C
Rationale: Verification of client identity and blood compatibility is the absolute priority to
prevent a fatal hemolytic transfusion reaction . Baseline vital signs, priming tubing, and
assessment are necessary but follow verification.
7. A charge nurse is assigning clients. Which client should be assigned to the most
experienced RN?
A. Client with diabetes requiring insulin administration
B. Client with pneumonia requiring q4h vital signs
C. Client with chest tubes and new-onset respiratory distress
D. Client with UTI requiring IV antibiotics
Correct Answer: C
Rationale: The client with chest tubes and new-onset respiratory distress is unstable and
requires complex assessment and intervention . Prioritization follows the ABC framework—
respiratory distress indicates an immediate threat to breathing.
8. A nurse is delegating to an LPN. Which task is appropriate?
A. Performing the initial admission assessment
B. Inserting an NG tube for decompression on a stable client
C. Teaching a client about insulin injection technique
D. Evaluating the effectiveness of pain medication
Correct Answer: B
Rationale: LPNs can perform stable, standard procedures like NG tube insertion . Initial
assessment, teaching, and evaluation require RN-level education and scope of practice.
9. A competent adult refuses a blood transfusion for religious reasons. Which actions should
the nurse take? (Select all that apply.)
, A. Verify the client understands risks
B. Document the refusal
C. Administer the transfusion if Hgb is critical
D. Notify the provider
E. Ask the family to override the decision
Correct Answers: A, B, D
Rationale: Competent adults have autonomy. The nurse ensures informed refusal,
documents, and notifies the provider . The nurse cannot administer against the client's wishes
or ask family to override the decision.
10. A nurse is preparing a client for a procedure that requires informed consent. The client
states, "I don't really understand what the doctor told me." Which action should the nurse
take?
A. Explain the procedure in detail to the client
B. Have the client sign the consent form anyway
C. Notify the provider that the client has questions
D. Ask the family to explain the procedure to the client
Correct Answer: C
Rationale: The provider is responsible for explaining risks, benefits, and alternatives. The
nurse should notify the provider that the client has questions before proceeding . It is outside
the nurse's scope to explain the surgical procedure.
11. A nurse is answering the unit telephone. A caller states, "My coworker was in a car
accident. Is she okay?" Which response is appropriate?
A. "She is in stable condition, but you will need to speak with her family for details."
B. "I will transfer you to her room so you can ask her directly."
C. "Come to the hospital and I will give you an update at the information desk."
D. "I am not able to confirm whether any particular person is being cared for at this facility."
Correct Answer: D
Rationale: Under HIPAA, the nurse may neither confirm nor deny that a client is receiving
care without the client's authorization . Options A and B both disclose protected health
information to an unverified caller.
Exam 180 Questions And 100% Correct
Answers Recently Updated
SECTION I: MANAGEMENT OF CARE
1. A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with COPD reporting shortness of breath, O2 saturation 88%
B. A client 2 days post-op requesting pain medication
C. A client with diabetes asking about diet
D. A client awaiting discharge instructions
Correct Answer: A
Rationale: Airway, Breathing, Circulation (ABC) priorities take precedence. An O2 saturation
of 88% in a COPD client indicates inadequate oxygenation requiring immediate assessment .
Pain management, education, and discharge planning are lower priorities when respiratory
compromise is present.
2. A competent adult client refuses a blood transfusion. Which action should the nurse take?
A. Administer the blood anyway
B. Notify the provider and document the refusal
C. Ask the family to convince the client
D. Restrain the client
Correct Answer: B
Rationale: A competent adult has the right to refuse treatment under the principle of
autonomy. The nurse must respect the refusal, notify the provider, and document the client's
decision . Administering treatment against the client's wishes constitutes battery.
3. Which task is appropriate to delegate to an unlicensed assistive personnel (UAP)?
A. Administering oral medications
B. Assessing a new admission
,C. Obtaining vital signs on a stable client
D. Teaching a client about insulin
Correct Answer: C
Rationale: UAPs can perform routine, stable tasks such as vital signs on stable clients .
Medication administration, assessment, and teaching require an RN license and clinical
judgment.
4. A nurse is triaging after a mass casualty event. Which client receives a RED tag?
A. Client with open femur fracture and weak pedal pulse
B. Client with massive head trauma and no respirations
C. Client with a sprained ankle
D. Client with minor lacerations
Correct Answer: A
Rationale: Red (Immediate) tag indicates life-threatening but survivable injuries requiring
rapid intervention. The femur fracture with weak pulse indicates vascular compromise . Black
tag is for clients with no respirations after repositioning.
5. A nurse is caring for a client who has a new diagnosis of terminal cancer. The client states,
"I don't want any more treatments." Which response demonstrates advocacy?
A. "You should discuss this with your oncologist before making any decisions."
B. "I will make sure your healthcare team knows your wishes and supports your decision."
C. "Let's wait until your family arrives so they can help you decide."
D. "I think you should reconsider because there are still treatment options available."
Correct Answer: B
Rationale: Advocacy means supporting the client's right to make informed decisions about
their own care . The nurse's role is to communicate the client's wishes to the healthcare team
and ensure they are respected, not to persuade or delay the client's decision.
6. A nurse is preparing to administer a blood transfusion. Which action is the highest priority
before initiating the transfusion?
,A. Obtain baseline vital signs
B. Prime the IV tubing with 0.9% sodium chloride
C. Verify the client's identity and blood product with another nurse
D. Assess the client's lung sounds
Correct Answer: C
Rationale: Verification of client identity and blood compatibility is the absolute priority to
prevent a fatal hemolytic transfusion reaction . Baseline vital signs, priming tubing, and
assessment are necessary but follow verification.
7. A charge nurse is assigning clients. Which client should be assigned to the most
experienced RN?
A. Client with diabetes requiring insulin administration
B. Client with pneumonia requiring q4h vital signs
C. Client with chest tubes and new-onset respiratory distress
D. Client with UTI requiring IV antibiotics
Correct Answer: C
Rationale: The client with chest tubes and new-onset respiratory distress is unstable and
requires complex assessment and intervention . Prioritization follows the ABC framework—
respiratory distress indicates an immediate threat to breathing.
8. A nurse is delegating to an LPN. Which task is appropriate?
A. Performing the initial admission assessment
B. Inserting an NG tube for decompression on a stable client
C. Teaching a client about insulin injection technique
D. Evaluating the effectiveness of pain medication
Correct Answer: B
Rationale: LPNs can perform stable, standard procedures like NG tube insertion . Initial
assessment, teaching, and evaluation require RN-level education and scope of practice.
9. A competent adult refuses a blood transfusion for religious reasons. Which actions should
the nurse take? (Select all that apply.)
, A. Verify the client understands risks
B. Document the refusal
C. Administer the transfusion if Hgb is critical
D. Notify the provider
E. Ask the family to override the decision
Correct Answers: A, B, D
Rationale: Competent adults have autonomy. The nurse ensures informed refusal,
documents, and notifies the provider . The nurse cannot administer against the client's wishes
or ask family to override the decision.
10. A nurse is preparing a client for a procedure that requires informed consent. The client
states, "I don't really understand what the doctor told me." Which action should the nurse
take?
A. Explain the procedure in detail to the client
B. Have the client sign the consent form anyway
C. Notify the provider that the client has questions
D. Ask the family to explain the procedure to the client
Correct Answer: C
Rationale: The provider is responsible for explaining risks, benefits, and alternatives. The
nurse should notify the provider that the client has questions before proceeding . It is outside
the nurse's scope to explain the surgical procedure.
11. A nurse is answering the unit telephone. A caller states, "My coworker was in a car
accident. Is she okay?" Which response is appropriate?
A. "She is in stable condition, but you will need to speak with her family for details."
B. "I will transfer you to her room so you can ask her directly."
C. "Come to the hospital and I will give you an update at the information desk."
D. "I am not able to confirm whether any particular person is being cared for at this facility."
Correct Answer: D
Rationale: Under HIPAA, the nurse may neither confirm nor deny that a client is receiving
care without the client's authorization . Options A and B both disclose protected health
information to an unverified caller.
