PN VATI FUNDAMENTALS 2023 EXAM TEST 2024\2025.
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
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.
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.
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.
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.
,PN VATI FUNDAMENTALS 2023 EXAM TEST 2024\2025.
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.
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.
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
Staging a pressure ulcer.
Rationale:
An LPN can collect data for the client and report findings to an RN. However, staging a pressure ulcer requires
advance knowledge and skill, and is outside the scope of practice of an LPN. An RN should assess the stage of a
complex wound, such as a pressure ulcer, and provide primary client teaching about pressure ulcer prevention
and care.
A nurse is reinforcing teaching about home safety with a client who is at risk for falls. Which of the following client
statements indicates an understanding of the teaching?
➖ "I will keep my floors well waxed."
➖ "I will take my shoes off when I come back into the house."
➖ "I will secure all of my electrical cords to the baseboard."
➖ "I will place area rugs on my tile floors."
, PN VATI FUNDAMENTALS 2023 EXAM TEST 2024\2025.
"I will secure all of my electrical cords to the baseboard."
Rationale:
Securing cords along the baseboards with electrical tape minimizes the tripping hazard for clients who are at risk
for falls.
A home health nurse is reinforcing teaching about infection control with a client who has hepatitis A. The nurse
should identify that which of the following client statements indicates an understanding of the teaching?
➖ "I will use a 10 to 1 solution of soap and water to clean my bathroom fixtures."
➖ "I will wear a surgical mask when around others."
➖ "I will wash my hands with soap and water for 15 seconds after having a bowel movement."
➖ "I will avoid contact with house plants."
"I will wash my hands with soap and water for 15 seconds after having a bowel movement."
Rationale:
The nurse should inform the client to wash their hands with soap and warm water for 15 seconds to remove
micro-organisms after having a bowel movement. This reduces the risk for transmitting the virus to others
because hepatitis A is a virus that is transmitted via the oral-fecal route.
A nurse at a rehabilitation facility is assisting with the admission of a client who has left-sided hemiplegia following
a stroke. Which of the following actions should the nurse take first?
➖ Demonstrate use of the call light.
➖ Give the client a list of assigned caregivers for the shift.
➖ Provide the client with nonskid footwear.
➖ Determine the client's mental status.
Determine the client's mental status.
Rationale:
The first action the nurse should take using the nursing process is to collect data from the client. By determining
the client's mental status, the nurse can determine whether the client has an increased risk for injury. Confusion
and disorientation can impair the client's judgment and can place the client at risk for falls.
A nurse is collecting data from an older adult client. Which of the following findings is an indication of infection?
➖ Decreased pulse rate
➖ Urinary retention
➖ Change in mental status
➖ Decreased respiratory rate
Change in mental status.
Rationale:
The nurse should identify that changes in the client's mental status, such as confusion and agitation, might be
manifestations of infection in an older adult client. Typical manifestations of infection might not occur with an
older adult client.
A nurse is performing a finger stick blood glucose test on a client who has diabetes. Which of the following actions
should the nurse take?
➖ Puncture the side of the finger.
➖ Squeeze the hand and finger tightly.
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
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.
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.
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.
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.
,PN VATI FUNDAMENTALS 2023 EXAM TEST 2024\2025.
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.
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.
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
Staging a pressure ulcer.
Rationale:
An LPN can collect data for the client and report findings to an RN. However, staging a pressure ulcer requires
advance knowledge and skill, and is outside the scope of practice of an LPN. An RN should assess the stage of a
complex wound, such as a pressure ulcer, and provide primary client teaching about pressure ulcer prevention
and care.
A nurse is reinforcing teaching about home safety with a client who is at risk for falls. Which of the following client
statements indicates an understanding of the teaching?
➖ "I will keep my floors well waxed."
➖ "I will take my shoes off when I come back into the house."
➖ "I will secure all of my electrical cords to the baseboard."
➖ "I will place area rugs on my tile floors."
, PN VATI FUNDAMENTALS 2023 EXAM TEST 2024\2025.
"I will secure all of my electrical cords to the baseboard."
Rationale:
Securing cords along the baseboards with electrical tape minimizes the tripping hazard for clients who are at risk
for falls.
A home health nurse is reinforcing teaching about infection control with a client who has hepatitis A. The nurse
should identify that which of the following client statements indicates an understanding of the teaching?
➖ "I will use a 10 to 1 solution of soap and water to clean my bathroom fixtures."
➖ "I will wear a surgical mask when around others."
➖ "I will wash my hands with soap and water for 15 seconds after having a bowel movement."
➖ "I will avoid contact with house plants."
"I will wash my hands with soap and water for 15 seconds after having a bowel movement."
Rationale:
The nurse should inform the client to wash their hands with soap and warm water for 15 seconds to remove
micro-organisms after having a bowel movement. This reduces the risk for transmitting the virus to others
because hepatitis A is a virus that is transmitted via the oral-fecal route.
A nurse at a rehabilitation facility is assisting with the admission of a client who has left-sided hemiplegia following
a stroke. Which of the following actions should the nurse take first?
➖ Demonstrate use of the call light.
➖ Give the client a list of assigned caregivers for the shift.
➖ Provide the client with nonskid footwear.
➖ Determine the client's mental status.
Determine the client's mental status.
Rationale:
The first action the nurse should take using the nursing process is to collect data from the client. By determining
the client's mental status, the nurse can determine whether the client has an increased risk for injury. Confusion
and disorientation can impair the client's judgment and can place the client at risk for falls.
A nurse is collecting data from an older adult client. Which of the following findings is an indication of infection?
➖ Decreased pulse rate
➖ Urinary retention
➖ Change in mental status
➖ Decreased respiratory rate
Change in mental status.
Rationale:
The nurse should identify that changes in the client's mental status, such as confusion and agitation, might be
manifestations of infection in an older adult client. Typical manifestations of infection might not occur with an
older adult client.
A nurse is performing a finger stick blood glucose test on a client who has diabetes. Which of the following actions
should the nurse take?
➖ Puncture the side of the finger.
➖ Squeeze the hand and finger tightly.
