PN VATI FUNDAMENTALS questions with verified
answers
A nurse is collecting data from a client who has an elevated temperature
with no sweating. Which of the following findings is an indication of
hypernatremia?
➖ Thirst
➖ Muscle twitching
➖ Headache
➖ Abdominal cramps Ans✔✔ -Thirst.
Rationale:
Thirst, combined with an elevated temperature and a lack of sweating,
can be an indication of hypernatremia.
A nurse is caring for a client who reports difficulty sleeping due to the
noise on the nursing unit. Which of the following actions should the
nurse take to reduce environmental noise?
➖ Close the door to the client's room.
➖ Turn off the alarms and beeps on monitoring equipment.
➖ Conduct change-of-shift report outside the client's door.
➖ Keep the television on low in the client's room. Ans✔✔ -Close the
door to the client's room.
,Rationale:
The nurse should close the door to the client's room whenever possible
to reduce environmental noise.
A nurse is reinforcing teaching about health promotion with a client.
Which of the following actions should the nurse take first to promote
effective learning?
➖ Identify areas of concern.
➖ Prioritize learning objectives.
➖ Demonstrate psychomotor skills.
➖ Observe nonverbal communication. Ans✔✔ -Identify areas of
concern.
Rationale:
The first action the nurse should take when using the nursing process is
to collect data from the client. Identifying and understanding the client's
concerns prior to reinforcing teaching promotes effective learning.
A home health nurse is assisting with the plan of care for a client. Which
of the following should the nurse include during the orientation phase of
the helping relationship?
➖ Review current client data.
➖ Assist to meet client goals.
,➖ Review shared memories of interactions with client.
➖ Clarify the role of this individual nurse. Ans✔✔ -Clarify the role of
this individual nurse.
Rationale:
The nurse should plan to establish a warm, caring relationship while
clarifying the role of each participant, which occurs during the
orientation phase of the relationship.
A nurse is preparing to assist with the admission of a client who has
pneumonia. Which of the following observations about the client's room
requires immediate attention?
➖ The wall BP gauge is missing.
➖ The room has no IV infusion pump.
➖ The examination light above the bed does not work.
➖ The wheel locks on the bed are malfunctioning. Ans✔✔ -The wheel
locks on the bed are malfunctioning.
Rationale:
The greatest risk to this client is injury from a fall when getting into or
out of a bed that is unstable due to malfunctioning locks. Therefore, the
priority is to report and replace the bed before admitting the client to the
room.
, A nurse is reinforcing teaching about health promotion with an older
adult client. Which of the following instructions to the client is an
example of secondary prevention?
➖ Participate in screenings for tuberculosis.
➖ Follow dietary recommendations to reduce the risk for osteoporosis.
➖ Limit alcohol intake to one drink per day.
➖ Perform yoga exercises three times per week. Ans✔✔ -Participate in
screenings for tuberculosis.
Rationale:
The nurse should encourage the client to participate in screenings for
tuberculosis, a secondary prevention measure. Secondary prevention
measures focus on diagnosis and early intervention.
A licensed practical nurse (LPN) is receiving change-of-shift report for a
client who had a stroke. For which of the following tasks should the
nurse request assistance from a registered nurse (RN)?
➖ Administering a cleansing enema
➖ Staging a pressure ulcer
➖ Inserting an indwelling urinary catheter
➖ Performing passive range-of-motion exercises Ans✔✔ -Staging a
pressure ulcer.
answers
A nurse is collecting data from a client who has an elevated temperature
with no sweating. Which of the following findings is an indication of
hypernatremia?
➖ Thirst
➖ Muscle twitching
➖ Headache
➖ Abdominal cramps Ans✔✔ -Thirst.
Rationale:
Thirst, combined with an elevated temperature and a lack of sweating,
can be an indication of hypernatremia.
A nurse is caring for a client who reports difficulty sleeping due to the
noise on the nursing unit. Which of the following actions should the
nurse take to reduce environmental noise?
➖ Close the door to the client's room.
➖ Turn off the alarms and beeps on monitoring equipment.
➖ Conduct change-of-shift report outside the client's door.
➖ Keep the television on low in the client's room. Ans✔✔ -Close the
door to the client's room.
,Rationale:
The nurse should close the door to the client's room whenever possible
to reduce environmental noise.
A nurse is reinforcing teaching about health promotion with a client.
Which of the following actions should the nurse take first to promote
effective learning?
➖ Identify areas of concern.
➖ Prioritize learning objectives.
➖ Demonstrate psychomotor skills.
➖ Observe nonverbal communication. Ans✔✔ -Identify areas of
concern.
Rationale:
The first action the nurse should take when using the nursing process is
to collect data from the client. Identifying and understanding the client's
concerns prior to reinforcing teaching promotes effective learning.
A home health nurse is assisting with the plan of care for a client. Which
of the following should the nurse include during the orientation phase of
the helping relationship?
➖ Review current client data.
➖ Assist to meet client goals.
,➖ Review shared memories of interactions with client.
➖ Clarify the role of this individual nurse. Ans✔✔ -Clarify the role of
this individual nurse.
Rationale:
The nurse should plan to establish a warm, caring relationship while
clarifying the role of each participant, which occurs during the
orientation phase of the relationship.
A nurse is preparing to assist with the admission of a client who has
pneumonia. Which of the following observations about the client's room
requires immediate attention?
➖ The wall BP gauge is missing.
➖ The room has no IV infusion pump.
➖ The examination light above the bed does not work.
➖ The wheel locks on the bed are malfunctioning. Ans✔✔ -The wheel
locks on the bed are malfunctioning.
Rationale:
The greatest risk to this client is injury from a fall when getting into or
out of a bed that is unstable due to malfunctioning locks. Therefore, the
priority is to report and replace the bed before admitting the client to the
room.
, A nurse is reinforcing teaching about health promotion with an older
adult client. Which of the following instructions to the client is an
example of secondary prevention?
➖ Participate in screenings for tuberculosis.
➖ Follow dietary recommendations to reduce the risk for osteoporosis.
➖ Limit alcohol intake to one drink per day.
➖ Perform yoga exercises three times per week. Ans✔✔ -Participate in
screenings for tuberculosis.
Rationale:
The nurse should encourage the client to participate in screenings for
tuberculosis, a secondary prevention measure. Secondary prevention
measures focus on diagnosis and early intervention.
A licensed practical nurse (LPN) is receiving change-of-shift report for a
client who had a stroke. For which of the following tasks should the
nurse request assistance from a registered nurse (RN)?
➖ Administering a cleansing enema
➖ Staging a pressure ulcer
➖ Inserting an indwelling urinary catheter
➖ Performing passive range-of-motion exercises Ans✔✔ -Staging a
pressure ulcer.
