VATI Fundamentals
A charge RN is providing an in-service about pt advocacy to a group of newly licensed nurses.
Which of the following examples should the nurse include? - ANS -Requesting a social services
consult for a client who states they cannot afford their medications
Requesting a social services consult for a client is an example of advocacy. The nurse is
protecting the client's health by providing resources that will assist the client to receive their
prescribed medications.
\A home health nurse is performing a home assessment for an older adult client. which of the
following statements by the client should alert the nurse to suggesst additional safety
measures? - ANS -""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 home health nurse is teaching about oral care to the family of a client who is in a coma.
Which of the following task should the nurse instruct the family to perform first? - ANS -Place the
pt in a side lying position.
The greatest risk to this client is injury from aspiration. Therefore, the first action the nurse
should instruct the family to perform is to place the client in a side-lying position. If the client
should not be placed in a side-lying position, then the nurse should instruct the family to turn the
client's head to the side to allow fluid to run out of the client's mouth
\A nurse is admitting a client who is to undergo a surgical procedure. Underlying the Patient
Self-determination act (PSDA) which of the following actions is the nurse's responsibility
regarding the pts advance directives? - ANS -Ask the client if they have created advance
directives.
The PSDA requires facilities to provide information to clients about their rights under state law to
make decisions, including the right to refuse treatment and formulate advance directives. Under
the act, staff should ask the client if they have advance directives, and the nurse should
document the client's response in the medical record.
\A nurse is assessing a client for hearing acuity by performing the Rinne Test. Which of the
following actions should the nurse take? - ANS -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.
\A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings.
The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding,
which of the following actions should the nurse take next? - ANS -Turn client onto side
The greatest risk to this client is aspiration from possible dislodgment of the NG tube and
aspirated stomach contents into the respiratory tract.
A charge RN is providing an in-service about pt advocacy to a group of newly licensed nurses.
Which of the following examples should the nurse include? - ANS -Requesting a social services
consult for a client who states they cannot afford their medications
Requesting a social services consult for a client is an example of advocacy. The nurse is
protecting the client's health by providing resources that will assist the client to receive their
prescribed medications.
\A home health nurse is performing a home assessment for an older adult client. which of the
following statements by the client should alert the nurse to suggesst additional safety
measures? - ANS -""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 home health nurse is teaching about oral care to the family of a client who is in a coma.
Which of the following task should the nurse instruct the family to perform first? - ANS -Place the
pt in a side lying position.
The greatest risk to this client is injury from aspiration. Therefore, the first action the nurse
should instruct the family to perform is to place the client in a side-lying position. If the client
should not be placed in a side-lying position, then the nurse should instruct the family to turn the
client's head to the side to allow fluid to run out of the client's mouth
\A nurse is admitting a client who is to undergo a surgical procedure. Underlying the Patient
Self-determination act (PSDA) which of the following actions is the nurse's responsibility
regarding the pts advance directives? - ANS -Ask the client if they have created advance
directives.
The PSDA requires facilities to provide information to clients about their rights under state law to
make decisions, including the right to refuse treatment and formulate advance directives. Under
the act, staff should ask the client if they have advance directives, and the nurse should
document the client's response in the medical record.
\A nurse is assessing a client for hearing acuity by performing the Rinne Test. Which of the
following actions should the nurse take? - ANS -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.
\A nurse is assessing a client who has an NG tube and is receiving continuous enteral feedings.
The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding,
which of the following actions should the nurse take next? - ANS -Turn client onto side
The greatest risk to this client is aspiration from possible dislodgment of the NG tube and
aspirated stomach contents into the respiratory tract.
