RN VATI Fundamentals 2019 Assessment
(answered) Retake 2022
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 pan of care?
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.
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?
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.
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?
B
A type B fire extinguisher is appropriate for putting out flammable liquid and gas fires. Disinfectant
solutions, such as isopropyl alcohol, are highly flammable liquids.
A nurse is reviewing a medical administration record for a client and discovers that an incorrect
medication was just administered. Which of the following actions should the nurse take first?
Check the client's vital signs.
The first action the nurse should take when using the nursing process is to assess the client for any
adverse effects of receiving the incorrect medication.
,A nurse in an operating room is performing surgical hand hygiene. Which of the following actions should
the nurse take?
Use a nail pick to clean the fingernails under running water.
Large amounts of micro-organisms can collect in dirt and organic material under fingernails. Scraping
out this material and ensuring its disposal via running water is essential for surgical hand hygiene.
A nurse is assessing four clients. Which of the following clients should the nurse identify as a potential
candidate for a prescription for mitten restraints?
A client who has dementia and has removed their enteral feeding tube repeatedly
Clients who have confusion and repeatedly remove or try to remove medical devices might require
mitten restraints to protect themselves from injury. However, the nurse should exhaust alternative
methods prior to requesting a restraint prescription.
A nurse is assessing a female client for a possible breast mass. Which of the following actions should the
nurse take?
Palpate the breasts using finger pads while the client is supine.
The nurse should use their finger pads to palpate the breasts while the client is supine.
A nurse at a health fair is performing screening assessments for older adults clients. Which of the
following is the priority mental health assessment that the nurse should include?
Depression
The greatest mental health risk for older adult clients is depression. Therefore, this is the priority
assessment to include.
A nurse is performing a health screening for a client. Which of the following findings should indicate to
the nurse that the client is at risk for coronary artery disease?
Triglyceride 180 mg/dL
A triglyceride level of 180 mg/dL is outside the expected reference range of 40 to 160 mg/dL for a male
client and 35 to 135 mg/dL for a female client, which places the client at risk for coronary artery disease.
, A RN is caring for a client who has terminal illness. The client request a DNR order, but their family
opposes the decision. Which of the following actions should the nurse take first.
Gather information to support the client's request for a DNR order.
Using the nursing process, the first action the nurse should take is to assess the situation by gathering
information to support the client's request for a DNR order. This information should include the client's
current clinical status, factors such as the client's spirituality, culture, and family dynamics, and evidence
from literature about the client's condition.
A nurse is assessing a client for hearing acuity by performing the Rinne test. Which of the following
actions should the nurse take when performing this test?
Move a vibrating tuning fork's prongs in front of the client's left or right ear canal.
The nurse should perform the Rinne test by placing the handle of a vibrating tuning fork on the client's
mastoid process and then moving the vibrating prongs 1 to 2 cm (0.4 to 0.8 in) in front of the client's left
or right ear canal. The Rinne test compares bone conduction with air conduction. The client is expected
to hear sound conduction by air for twice as long as bone conduction.
Using the nursing process, the first action the nurse should take is to assess the situation by gathering
information to support the client's request for a DNR order. This information should include the client's
current clinical status, factors such as the client's spirituality, culture, and family dynamics, and evidence
from literature about the client's condition.
"I use space heaters to keep warm in the winter."
A common environmental hazard in the home is the use of space heaters, which can increase the risk of
fire.
A nurse is preparing to administer an intramuscular injection to a client. At which of the the following
angels should the nurse pan to insert the needle?
90°
The nurse should plan to insert the needle at a 90° angle when administering medication via the
intramuscular route. The intramuscular route promotes quicker medication absorption into the muscle
than the other routes of medication administration.
(answered) Retake 2022
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 pan of care?
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.
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?
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.
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?
B
A type B fire extinguisher is appropriate for putting out flammable liquid and gas fires. Disinfectant
solutions, such as isopropyl alcohol, are highly flammable liquids.
A nurse is reviewing a medical administration record for a client and discovers that an incorrect
medication was just administered. Which of the following actions should the nurse take first?
Check the client's vital signs.
The first action the nurse should take when using the nursing process is to assess the client for any
adverse effects of receiving the incorrect medication.
,A nurse in an operating room is performing surgical hand hygiene. Which of the following actions should
the nurse take?
Use a nail pick to clean the fingernails under running water.
Large amounts of micro-organisms can collect in dirt and organic material under fingernails. Scraping
out this material and ensuring its disposal via running water is essential for surgical hand hygiene.
A nurse is assessing four clients. Which of the following clients should the nurse identify as a potential
candidate for a prescription for mitten restraints?
A client who has dementia and has removed their enteral feeding tube repeatedly
Clients who have confusion and repeatedly remove or try to remove medical devices might require
mitten restraints to protect themselves from injury. However, the nurse should exhaust alternative
methods prior to requesting a restraint prescription.
A nurse is assessing a female client for a possible breast mass. Which of the following actions should the
nurse take?
Palpate the breasts using finger pads while the client is supine.
The nurse should use their finger pads to palpate the breasts while the client is supine.
A nurse at a health fair is performing screening assessments for older adults clients. Which of the
following is the priority mental health assessment that the nurse should include?
Depression
The greatest mental health risk for older adult clients is depression. Therefore, this is the priority
assessment to include.
A nurse is performing a health screening for a client. Which of the following findings should indicate to
the nurse that the client is at risk for coronary artery disease?
Triglyceride 180 mg/dL
A triglyceride level of 180 mg/dL is outside the expected reference range of 40 to 160 mg/dL for a male
client and 35 to 135 mg/dL for a female client, which places the client at risk for coronary artery disease.
, A RN is caring for a client who has terminal illness. The client request a DNR order, but their family
opposes the decision. Which of the following actions should the nurse take first.
Gather information to support the client's request for a DNR order.
Using the nursing process, the first action the nurse should take is to assess the situation by gathering
information to support the client's request for a DNR order. This information should include the client's
current clinical status, factors such as the client's spirituality, culture, and family dynamics, and evidence
from literature about the client's condition.
A nurse is assessing a client for hearing acuity by performing the Rinne test. Which of the following
actions should the nurse take when performing this test?
Move a vibrating tuning fork's prongs in front of the client's left or right ear canal.
The nurse should perform the Rinne test by placing the handle of a vibrating tuning fork on the client's
mastoid process and then moving the vibrating prongs 1 to 2 cm (0.4 to 0.8 in) in front of the client's left
or right ear canal. The Rinne test compares bone conduction with air conduction. The client is expected
to hear sound conduction by air for twice as long as bone conduction.
Using the nursing process, the first action the nurse should take is to assess the situation by gathering
information to support the client's request for a DNR order. This information should include the client's
current clinical status, factors such as the client's spirituality, culture, and family dynamics, and evidence
from literature about the client's condition.
"I use space heaters to keep warm in the winter."
A common environmental hazard in the home is the use of space heaters, which can increase the risk of
fire.
A nurse is preparing to administer an intramuscular injection to a client. At which of the the following
angels should the nurse pan to insert the needle?
90°
The nurse should plan to insert the needle at a 90° angle when administering medication via the
intramuscular route. The intramuscular route promotes quicker medication absorption into the muscle
than the other routes of medication administration.
