VATI Fundamentals Post-Assessment Exam V2 | Fundamentals of
Nursing (VATI Fundamentals Post-Assessment Exam) | Chamberlain
1. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following actions should the nurse take to ensure the correct site is selected?
A. Locate the greater trochanter and the anterior superior iliac spine.
B. Measure two fingerbreadths below the acromion process.
C. Identify the mid-portion of the lateral thigh.
D. Find the iliac crest and the posterior superior iliac spine.
Answer: A
Rationale: The ventrogluteal site is the preferred site for intramuscular injections in adults
because it is deep and away from major blood vessels and nerves. To locate this site, the
nurse places the palm over the greater trochanter and the index finger on the anterior
superior iliac spine. Options B and C describe the deltoid and vastus lateralis sites
respectively, while D is not a standard landmarking technique for IM injections.
2. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the
following food items should the nurse offer?
A. Vanilla pudding
B. Orange juice with pulp
C. Apple juice
D. Cream of chicken soup
Answer: C
Rationale: Clear liquids are those that are transparent at room temperature and do not
contain solids or pulp. Apple juice is a clear liquid and is appropriate for this diet. Pudding,
orange juice with pulp, and cream-based soups are considered full liquids and are
contraindicated for a clear liquid restriction.
3. A nurse is preparing to transfer a client from a bed to a chair. Which of the following
actions should the nurse take first?
A. Position the chair at a 45-degree angle to the bed.
B. Apply a gait belt around the client’s waist.
C. Lock the brakes on the bed and the chair.
D. Assess the client’s ability to assist with the transfer.
,Answer: D
Rationale: According to the nursing process, assessment is the first step in any
intervention. The nurse must determine the client’s strength, balance, and cognitive status
to decide if one or two staff members are needed or if mechanical assistance is required.
While positioning the chair and using a gait belt are important safety steps, they follow the
initial assessment of the client’s physical status.
4. A nurse is documenting in a client’s medical record. Which of the following entries is an
example of objective data?
A. The client states, ‘I feel very nauseous today.’
B. The client appears restless and is wringing their hands.
C. The client reports a pain level of 8 on a scale of 0 to 10.
D. The client’s spouse mentions the client did not sleep well.
Answer: B
Rationale: Objective data consists of observable and measurable information gathered
through the physical senses. Restlessness and hand-wringing are physical behaviors that
the nurse can see. Statements made by the client or family members are considered
subjective data and should be documented using the speaker’s own words in quotation
marks.
5. A nurse is teaching a client about the use of a cane. Which of the following instructions
should the nurse include?
A. Hold the cane on the stronger side of the body.
B. Move the stronger leg forward first when walking.
C. Place the cane 25 cm (10 in) in front of the feet.
D. Keep the elbow flexed at a 45-degree angle.
Answer: A
Rationale: A cane should be held on the unaffected (stronger) side to provide the best
support and balance. When walking, the client moves the cane forward first, followed by
the affected leg, and then the stronger leg. The elbow should be flexed at a 15 to 30-degree
angle, not 45, to ensure proper ergonomics and stability.
6. A nurse is reviewing isolation precautions for a client who has a localized herpes zoster
infection. Which of the following types of precautions should the nurse initiate?
A. Standard precautions
B. Airborne precautions
C. Droplet precautions
, D. Protective environment
Answer: A
Rationale: For a localized herpes zoster infection (shingles) in a client with an intact
immune system, standard precautions are sufficient as long as the lesions are covered.
Disseminated herpes zoster or localized infection in an immunocompromised client would
require both airborne and contact precautions. Droplet precautions are not necessary for
shingles as the virus is not spread through large-particle respiratory droplets.
7. A nurse is performing a skin assessment on an older adult client. Which of the following
findings should the nurse expect due to the aging process?
A. Decreased subcutaneous fat
B. Increased skin elasticity
C. Increased sebaceous gland activity
D. Thickening of the epidermal layer
Answer: A
Rationale: The aging process results in a loss of subcutaneous fat, which makes the skin
more fragile and prone to injury. Older adults also experience decreased skin elasticity
(turgor) and decreased oil production due to reduced sebaceous gland activity. The
epidermis actually thins rather than thickens, contributing to the translucent appearance of
elderly skin.
8. A nurse is providing discharge teaching to a client who has a new prescription for home
oxygen. Which of the following instructions should the nurse include?
A. Use petroleum jelly to soothe nasal irritation.
B. Wear wool clothing to keep warm while using oxygen.
C. Ensure all electrical equipment in the room is grounded.
D. Check the oxygen equipment once every month.
Answer: C
Rationale: Oxygen supports combustion, so all electrical equipment must be grounded to
prevent sparks that could cause a fire. Petroleum-based products are flammable and
should be replaced with water-based lubricants for nasal comfort. Wool and synthetic
fabrics can generate static electricity and should be replaced with cotton clothing to
minimize fire risk.
9. A nurse is assessing a client’s radial pulse and notes that the rhythm is irregular. Which of
the following actions should the nurse take?
A. Measure the pulse at the carotid site for 30 seconds.
Nursing (VATI Fundamentals Post-Assessment Exam) | Chamberlain
1. A nurse is preparing to administer an intramuscular injection to an adult client. Which of
the following actions should the nurse take to ensure the correct site is selected?
A. Locate the greater trochanter and the anterior superior iliac spine.
B. Measure two fingerbreadths below the acromion process.
C. Identify the mid-portion of the lateral thigh.
D. Find the iliac crest and the posterior superior iliac spine.
Answer: A
Rationale: The ventrogluteal site is the preferred site for intramuscular injections in adults
because it is deep and away from major blood vessels and nerves. To locate this site, the
nurse places the palm over the greater trochanter and the index finger on the anterior
superior iliac spine. Options B and C describe the deltoid and vastus lateralis sites
respectively, while D is not a standard landmarking technique for IM injections.
2. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the
following food items should the nurse offer?
A. Vanilla pudding
B. Orange juice with pulp
C. Apple juice
D. Cream of chicken soup
Answer: C
Rationale: Clear liquids are those that are transparent at room temperature and do not
contain solids or pulp. Apple juice is a clear liquid and is appropriate for this diet. Pudding,
orange juice with pulp, and cream-based soups are considered full liquids and are
contraindicated for a clear liquid restriction.
3. A nurse is preparing to transfer a client from a bed to a chair. Which of the following
actions should the nurse take first?
A. Position the chair at a 45-degree angle to the bed.
B. Apply a gait belt around the client’s waist.
C. Lock the brakes on the bed and the chair.
D. Assess the client’s ability to assist with the transfer.
,Answer: D
Rationale: According to the nursing process, assessment is the first step in any
intervention. The nurse must determine the client’s strength, balance, and cognitive status
to decide if one or two staff members are needed or if mechanical assistance is required.
While positioning the chair and using a gait belt are important safety steps, they follow the
initial assessment of the client’s physical status.
4. A nurse is documenting in a client’s medical record. Which of the following entries is an
example of objective data?
A. The client states, ‘I feel very nauseous today.’
B. The client appears restless and is wringing their hands.
C. The client reports a pain level of 8 on a scale of 0 to 10.
D. The client’s spouse mentions the client did not sleep well.
Answer: B
Rationale: Objective data consists of observable and measurable information gathered
through the physical senses. Restlessness and hand-wringing are physical behaviors that
the nurse can see. Statements made by the client or family members are considered
subjective data and should be documented using the speaker’s own words in quotation
marks.
5. A nurse is teaching a client about the use of a cane. Which of the following instructions
should the nurse include?
A. Hold the cane on the stronger side of the body.
B. Move the stronger leg forward first when walking.
C. Place the cane 25 cm (10 in) in front of the feet.
D. Keep the elbow flexed at a 45-degree angle.
Answer: A
Rationale: A cane should be held on the unaffected (stronger) side to provide the best
support and balance. When walking, the client moves the cane forward first, followed by
the affected leg, and then the stronger leg. The elbow should be flexed at a 15 to 30-degree
angle, not 45, to ensure proper ergonomics and stability.
6. A nurse is reviewing isolation precautions for a client who has a localized herpes zoster
infection. Which of the following types of precautions should the nurse initiate?
A. Standard precautions
B. Airborne precautions
C. Droplet precautions
, D. Protective environment
Answer: A
Rationale: For a localized herpes zoster infection (shingles) in a client with an intact
immune system, standard precautions are sufficient as long as the lesions are covered.
Disseminated herpes zoster or localized infection in an immunocompromised client would
require both airborne and contact precautions. Droplet precautions are not necessary for
shingles as the virus is not spread through large-particle respiratory droplets.
7. A nurse is performing a skin assessment on an older adult client. Which of the following
findings should the nurse expect due to the aging process?
A. Decreased subcutaneous fat
B. Increased skin elasticity
C. Increased sebaceous gland activity
D. Thickening of the epidermal layer
Answer: A
Rationale: The aging process results in a loss of subcutaneous fat, which makes the skin
more fragile and prone to injury. Older adults also experience decreased skin elasticity
(turgor) and decreased oil production due to reduced sebaceous gland activity. The
epidermis actually thins rather than thickens, contributing to the translucent appearance of
elderly skin.
8. A nurse is providing discharge teaching to a client who has a new prescription for home
oxygen. Which of the following instructions should the nurse include?
A. Use petroleum jelly to soothe nasal irritation.
B. Wear wool clothing to keep warm while using oxygen.
C. Ensure all electrical equipment in the room is grounded.
D. Check the oxygen equipment once every month.
Answer: C
Rationale: Oxygen supports combustion, so all electrical equipment must be grounded to
prevent sparks that could cause a fire. Petroleum-based products are flammable and
should be replaced with water-based lubricants for nasal comfort. Wool and synthetic
fabrics can generate static electricity and should be replaced with cotton clothing to
minimize fire risk.
9. A nurse is assessing a client’s radial pulse and notes that the rhythm is irregular. Which of
the following actions should the nurse take?
A. Measure the pulse at the carotid site for 30 seconds.
