Master the VATI Green Light Predictor with 200
Practice Questions and Rationales Covering
Pharmacology, Prioritization, Safety, and Clinical
Judgment for Forms A, B & C – Updated
2026/2027
Comprehensive Practice Questions with Rationales
Question Answer & Rationale
Answer: A) Hyperreflexia
1. A nurse is caring for a client who has opioid Rationale: Opioid withdrawal is characterized by
use disorder and is experiencing withdrawal. hyperactivity of the autonomic nervous system. Signs
Which of the following findings should the nurse include hyperreflexia, mydriasis (pupil dilation), dysphori
expect? and hyperthermia. Miosis and euphoria are signs of opio
intoxication, not withdrawal .
Answer: B) Place the client in a low-Fowler's position
2. A nurse is assessing a client who is Rationale: For wound dehiscence, the nurse should plac
postoperative following abdominal surgery. The the client in a low-Fowler's or supine position with knees
client states, "I feel like my incision ripped bent to reduce tension on the incision. Applying a sterile
open." The nurse notes dehiscence of the saline-moistened dressing (not dry) over the wound and
incision. Which of the following actions should notifying the provider are also appropriate. The Valsalva
the nurse take? maneuver increases intra-abdominal pressure and shoul
avoided .
,Question Answer & Rationale
Answer: C) Paradoxical pulse
Rationale: Paradoxical pulse (pulsus paradoxus) is a drop
systolic blood pressure >10 mmHg during inspiration,
3. A nurse is assessing a client who has
indicating cardiac tamponade—a life-threatening
pericarditis. Which of the following findings is
complication of pericarditis. This finding signals potentia
the priority?
cardiac compression and requires immediate interventio
taking priority over other manifestations like chest pain o
friction rub .
Answer: C) A client who has a traumatic arm amputatio
Rationale: In disaster triage (using the START system), cli
with life-threatening but survivable injuries are the highe
4. A nurse is performing triage following a
priority (Red/Immediate). A traumatic amputation with
natural disaster. Which of the following clients
hemorrhage is immediately life-threatening but potentia
should the nurse identify as the highest priority
survivable with rapid intervention. Clients with agonal
to receive care?
respirations or unresponsiveness with severe head injury
typically classified as Black/Expectant (lowest priority du
poor prognosis) .
Answer: B. Egg whites
5. A nurse is providing dietary teaching to a
Rationale: Egg whites are low in cholesterol and fat, mak
client who has an increased cholesterol level.
them a good choice for a low-cholesterol diet. Beef liver,
Which of the following foods should the nurse
steamed clams, and broiled lobster are high in cholestero
recommend?
and should be avoided or limited .
Answer: B) Ototoxicity
6. A nurse is planning to administer vancomycin
Rationale: Vancomycin is an antibiotic that can cause
to a client who has an infected wound. The
ototoxicity (tinnitus and hearing loss) and nephrotoxicity
nurse should plan to monitor for which of the
Monitoring serum trough levels is essential to prevent
following adverse reactions?
toxicity .
7. A nurse in a mental health facility is Answer: D. Lean in slightly when speaking to the client
interviewing a newly admitted client. Which of Rationale: Leaning in slightly conveys interest and
,Question Answer & Rationale
the following actions should the nurse take engagement. Forcing eye contact can be threatening to
when conducting the interview? clients with mental health conditions. Seating the client
between the nurse and the door is unsafe (client may blo
exit). A distance of 3.7 m is too far for therapeutic
communication .
Answer: A. A 68-year-old client who had a myocardial
infarction 2 days ago and reports chest pain 4 on a scale
0 to 10
8. A nurse on a medical unit has just received
Rationale: Chest pain in a post-MI client may indicate
change-of-shift report. Which of the following
reinfarction or unstable angina and is the highest priority
clients should the nurse assess first?
While the other clients have urgent needs, chest pain is
potentially life-threatening and requires immediate
assessment .
Answer: C. Avocados
9. A nurse is assessing a client prior to
Rationale: Cross-reactivity exists between latex and cert
performing a blood draw. The nurse should
foods including avocados, bananas, kiwi, and chestnuts.
identify that an allergy to which of the following
Clients with allergies to these foods may also have latex
foods can indicate that the client has an allergy
sensitivity. Peanuts, shellfish, and eggs are not specificall
to latex?
associated with latex allergy .
Answer: B. Troponin I 1.8 ng/mL
10. A nurse is caring for a client who reports
Rationale: Troponin I is a highly specific and sensitive car
chest pain. Which of the following findings
biomarker. An elevated level (normal is typically <0.03
indicates myocardial damage?
ng/mL) indicates myocardial damage or injury .
Answer: D. "Try to have your baby empty your breasts w
each feeding."
11. A nurse is providing teaching to a client who
Rationale: Emptying breasts completely with each feedin
is breastfeeding and has mastitis. Which of the
prevents milk stasis, which is a risk factor for mastitis.
following instructions should the nurse include?
Underwire bras can compress milk ducts and should be
avoided .
, Question Answer & Rationale
Answer: A. Decreased reflexes
12. A nurse is caring for a client who has heart
Rationale: Loop diuretics can cause electrolyte imbalanc
failure and has started taking a loop diuretic.
particularly hypokalemia and hyponatremia. Decreased
Which of the following findings indicates the
reflexes indicate hypokalemia, which is an adverse effect
client is experiencing an adverse effect of the
Weight gain and jugular vein distention indicate worsenin
medication?
heart failure .
13. A nurse is collecting data from a parent of a Answer: Long-term use of immunosuppressants
preschooler at a well-child visit. Which of the Rationale: Live vaccines like MMR are contraindicated in
following findings is a contraindication to a clients who are immunocompromised due to the risk of
measles, mumps, and rubella (MMR) causing the disease. Other contraindications include
immunization? pregnancy and severe allergy to vaccine components .
14. A nurse is caring for a client who is asking Answer: "It is a light stroking of the skin during a uterin
about the technique of effleurage and its use in contraction."
labor and delivery. Which of the following Rationale: Effleurage is a light, rhythmic stroking massag
responses should the nurse make regarding this technique used during labor to promote relaxation and
technique? reduce pain perception .
Answer: Increased heart rate
15. A nurse is reinforcing teaching with an older
Rationale: In heart failure, digoxin increases the force of
adult client who has a new prescription for
myocardial contraction (positive inotropy) and decreases
digoxin for heart failure. Which of the following
heart rate (negative chronotropy). An increased heart rat
effects should the nurse include as an expected
would be a sign of digoxin toxicity or a lack of therapeuti
outcome of this medication?
effect .
16. A nurse is caring for a client who is 5 days
postoperative following abdominal surgery. The Answer: Place the client in a side-lying position
client tells the nurse that he was coughing and Rationale: For evisceration, the immediate action is to p
"felt a pop" at the incision site. The nurse the client in a supine position with knees bent to reduce
examines the incision and finds wound abdominal tension and prevent further protrusion of org
dehiscence and evisceration. Which of the This is often described as a low-Fowler's or supine positio
following actions should the nurse take first? not side-lying. The key is to reduce tension on the abdom
Practice Questions and Rationales Covering
Pharmacology, Prioritization, Safety, and Clinical
Judgment for Forms A, B & C – Updated
2026/2027
Comprehensive Practice Questions with Rationales
Question Answer & Rationale
Answer: A) Hyperreflexia
1. A nurse is caring for a client who has opioid Rationale: Opioid withdrawal is characterized by
use disorder and is experiencing withdrawal. hyperactivity of the autonomic nervous system. Signs
Which of the following findings should the nurse include hyperreflexia, mydriasis (pupil dilation), dysphori
expect? and hyperthermia. Miosis and euphoria are signs of opio
intoxication, not withdrawal .
Answer: B) Place the client in a low-Fowler's position
2. A nurse is assessing a client who is Rationale: For wound dehiscence, the nurse should plac
postoperative following abdominal surgery. The the client in a low-Fowler's or supine position with knees
client states, "I feel like my incision ripped bent to reduce tension on the incision. Applying a sterile
open." The nurse notes dehiscence of the saline-moistened dressing (not dry) over the wound and
incision. Which of the following actions should notifying the provider are also appropriate. The Valsalva
the nurse take? maneuver increases intra-abdominal pressure and shoul
avoided .
,Question Answer & Rationale
Answer: C) Paradoxical pulse
Rationale: Paradoxical pulse (pulsus paradoxus) is a drop
systolic blood pressure >10 mmHg during inspiration,
3. A nurse is assessing a client who has
indicating cardiac tamponade—a life-threatening
pericarditis. Which of the following findings is
complication of pericarditis. This finding signals potentia
the priority?
cardiac compression and requires immediate interventio
taking priority over other manifestations like chest pain o
friction rub .
Answer: C) A client who has a traumatic arm amputatio
Rationale: In disaster triage (using the START system), cli
with life-threatening but survivable injuries are the highe
4. A nurse is performing triage following a
priority (Red/Immediate). A traumatic amputation with
natural disaster. Which of the following clients
hemorrhage is immediately life-threatening but potentia
should the nurse identify as the highest priority
survivable with rapid intervention. Clients with agonal
to receive care?
respirations or unresponsiveness with severe head injury
typically classified as Black/Expectant (lowest priority du
poor prognosis) .
Answer: B. Egg whites
5. A nurse is providing dietary teaching to a
Rationale: Egg whites are low in cholesterol and fat, mak
client who has an increased cholesterol level.
them a good choice for a low-cholesterol diet. Beef liver,
Which of the following foods should the nurse
steamed clams, and broiled lobster are high in cholestero
recommend?
and should be avoided or limited .
Answer: B) Ototoxicity
6. A nurse is planning to administer vancomycin
Rationale: Vancomycin is an antibiotic that can cause
to a client who has an infected wound. The
ototoxicity (tinnitus and hearing loss) and nephrotoxicity
nurse should plan to monitor for which of the
Monitoring serum trough levels is essential to prevent
following adverse reactions?
toxicity .
7. A nurse in a mental health facility is Answer: D. Lean in slightly when speaking to the client
interviewing a newly admitted client. Which of Rationale: Leaning in slightly conveys interest and
,Question Answer & Rationale
the following actions should the nurse take engagement. Forcing eye contact can be threatening to
when conducting the interview? clients with mental health conditions. Seating the client
between the nurse and the door is unsafe (client may blo
exit). A distance of 3.7 m is too far for therapeutic
communication .
Answer: A. A 68-year-old client who had a myocardial
infarction 2 days ago and reports chest pain 4 on a scale
0 to 10
8. A nurse on a medical unit has just received
Rationale: Chest pain in a post-MI client may indicate
change-of-shift report. Which of the following
reinfarction or unstable angina and is the highest priority
clients should the nurse assess first?
While the other clients have urgent needs, chest pain is
potentially life-threatening and requires immediate
assessment .
Answer: C. Avocados
9. A nurse is assessing a client prior to
Rationale: Cross-reactivity exists between latex and cert
performing a blood draw. The nurse should
foods including avocados, bananas, kiwi, and chestnuts.
identify that an allergy to which of the following
Clients with allergies to these foods may also have latex
foods can indicate that the client has an allergy
sensitivity. Peanuts, shellfish, and eggs are not specificall
to latex?
associated with latex allergy .
Answer: B. Troponin I 1.8 ng/mL
10. A nurse is caring for a client who reports
Rationale: Troponin I is a highly specific and sensitive car
chest pain. Which of the following findings
biomarker. An elevated level (normal is typically <0.03
indicates myocardial damage?
ng/mL) indicates myocardial damage or injury .
Answer: D. "Try to have your baby empty your breasts w
each feeding."
11. A nurse is providing teaching to a client who
Rationale: Emptying breasts completely with each feedin
is breastfeeding and has mastitis. Which of the
prevents milk stasis, which is a risk factor for mastitis.
following instructions should the nurse include?
Underwire bras can compress milk ducts and should be
avoided .
, Question Answer & Rationale
Answer: A. Decreased reflexes
12. A nurse is caring for a client who has heart
Rationale: Loop diuretics can cause electrolyte imbalanc
failure and has started taking a loop diuretic.
particularly hypokalemia and hyponatremia. Decreased
Which of the following findings indicates the
reflexes indicate hypokalemia, which is an adverse effect
client is experiencing an adverse effect of the
Weight gain and jugular vein distention indicate worsenin
medication?
heart failure .
13. A nurse is collecting data from a parent of a Answer: Long-term use of immunosuppressants
preschooler at a well-child visit. Which of the Rationale: Live vaccines like MMR are contraindicated in
following findings is a contraindication to a clients who are immunocompromised due to the risk of
measles, mumps, and rubella (MMR) causing the disease. Other contraindications include
immunization? pregnancy and severe allergy to vaccine components .
14. A nurse is caring for a client who is asking Answer: "It is a light stroking of the skin during a uterin
about the technique of effleurage and its use in contraction."
labor and delivery. Which of the following Rationale: Effleurage is a light, rhythmic stroking massag
responses should the nurse make regarding this technique used during labor to promote relaxation and
technique? reduce pain perception .
Answer: Increased heart rate
15. A nurse is reinforcing teaching with an older
Rationale: In heart failure, digoxin increases the force of
adult client who has a new prescription for
myocardial contraction (positive inotropy) and decreases
digoxin for heart failure. Which of the following
heart rate (negative chronotropy). An increased heart rat
effects should the nurse include as an expected
would be a sign of digoxin toxicity or a lack of therapeuti
outcome of this medication?
effect .
16. A nurse is caring for a client who is 5 days
postoperative following abdominal surgery. The Answer: Place the client in a side-lying position
client tells the nurse that he was coughing and Rationale: For evisceration, the immediate action is to p
"felt a pop" at the incision site. The nurse the client in a supine position with knees bent to reduce
examines the incision and finds wound abdominal tension and prevent further protrusion of org
dehiscence and evisceration. Which of the This is often described as a low-Fowler's or supine positio
following actions should the nurse take first? not side-lying. The key is to reduce tension on the abdom
