VATI Fundamentals Post-Assessment Exam V1 | Fundamentals of
Nursing (VATI Fundamentals Post-Assessment Exam) | Chamberlain
1. A nurse is preparing to care for a client who has Clostridium difficile (C. diff). Which of the
following hand hygiene practices should the nurse implement?
A. Use an alcohol-based hand rub for 15 seconds.
B. Wash hands with non-antimicrobial soap and water.
C. Use a chlorhexidine gluconate solution for hand hygiene.
D. Wipe hands with a disposable germicidal wipe.
Answer: B
Rationale: C. difficile is a spore-forming bacterium that is resistant to alcohol-based hand
rubs. Washing hands with soap and water is required because the mechanical friction and
rinsing action are necessary to physically remove spores from the skin. Using alcohol-based
rubs or germicidal wipes is ineffective against these specific spores and can lead to cross-
contamination.
2. A nurse discovers a small fire in a client’s wastebasket. Which of the following actions
should the nurse take first?
A. Move the client to a safe area away from the fire.
B. Attempt to extinguish the fire using a fire extinguisher.
C. Close all doors and windows to contain the fire.
D. Activate the facility’s fire alarm system.
Answer: A
Rationale: According to the RACE acronym for fire safety, ‘R’ stands for Rescue/Remove,
which is always the first priority to ensure client safety. Activating the alarm (Alarm) and
containing the fire (Confine) are subsequent steps. Extinguishing the fire (Extinguish) is the
final step and should only be performed if it is safe to do so after all clients are secured.
3. A nurse is caring for a client who is post-operative and requires an intramuscular (IM)
injection. Which of the following sites is the safest for a large volume injection in an adult?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus lateralis
,Answer: B
Rationale: The ventrogluteal site is considered the safest and most preferred site for IM
injections in adults because it is located away from major nerves and blood vessels. The
dorsogluteal site is no longer recommended due to the proximity of the sciatic nerve. The
deltoid is used for small volumes, and while the vastus lateralis is safe, it is less preferred
than the ventrogluteal for large-volume injections in mobile adults.
4. A nurse is documenting in a client’s electronic health record. Which of the following entries
represents a professional and objective standard of documentation?
A. The client seems angry today and refused breakfast.
B. The client appears to be having a good day.
C. The client stated, ‘I feel frustrated because I cannot go home yet.’
D. The client was uncooperative during the physical exam.
Answer: C
Rationale: Documentation should be objective, factual, and avoid subjective
interpretations or judgmental language. Using a direct quote from the client provides an
accurate representation of their feelings without nurse bias. Terms like ‘seems,’ ‘appears,’
or ‘uncooperative’ are subjective and do not provide clear, measurable clinical data.
5. A nurse is caring for a client who is on airborne precautions. Which of the following
personal protective equipment (PPE) is essential for the nurse to wear?
A. Face shield
B. Surgical mask
C. N95 respirator
D. Gown and gloves only
Answer: C
Rationale: Airborne precautions are required for pathogens that remain suspended in the
air for long periods, such as tuberculosis or varicella. An N95 respirator is necessary to
filter out these small particles that a standard surgical mask cannot block. Surgical masks
are appropriate for droplet precautions, while gowns and gloves are standard for contact
precautions.
6. A nurse is assessing a client for orthostatic hypotension. Which of the following findings
indicates the client is experiencing this condition?
A. An increase in diastolic pressure of 5 mm Hg when sitting.
B. A decrease in systolic pressure of 20 mm Hg when standing.
C. An increase in heart rate of 5 beats per minute when standing.
, D. A decrease in systolic pressure of 5 mm Hg when sitting.
Answer: B
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mm Hg or a drop in diastolic blood pressure of at least 10 mm Hg within 3 minutes
of standing. This occurs because the cardiovascular system fails to compensate for the
change in position. Minor changes in heart rate or small decreases in pressure are
considered normal physiological responses and do not meet the diagnostic criteria.
7. A nurse is providing teaching to a client about using a cane for ambulation. Which of the
following instructions should the nurse include?
A. Hold the cane on the weaker side of the body.
B. Hold the cane on the stronger side of the body.
C. Move the stronger leg forward first when walking.
D. Keep the elbow straight when holding the cane handle.
Answer: B
Rationale: To provide maximum support and balance, a cane should be held on the
unaffected (stronger) side. This allows the cane and the weaker leg to move forward
together, distributing weight evenly. The elbow should be slightly flexed (about 15 to 30
degrees), not straight, to allow for comfort and proper leverage during ambulation.
8. A nurse is caring for a client who is receiving enteral tube feedings. Which of the following
actions is the priority before administering the next feeding?
A. Flush the tube with 30 mL of warm water.
B. Warm the formula to room temperature.
C. Check the gastric residual volume.
D. Verify the placement of the tube.
Answer: D
Rationale: Verifying the tube placement is the highest priority to prevent aspiration, which
can occur if the tube has migrated to the lungs. Once placement is confirmed, checking
residual volume and flushing the tube are standard steps to ensure gastric emptying and
patency. While warming the formula is for comfort, it is not a safety priority compared to
preventing aspiration.
9. A nurse is teaching a client about a high-fiber diet. Which of the following food choices
should the nurse recommend?
A. White bread and canned fruit.
B. Peeled apples and white rice.
Nursing (VATI Fundamentals Post-Assessment Exam) | Chamberlain
1. A nurse is preparing to care for a client who has Clostridium difficile (C. diff). Which of the
following hand hygiene practices should the nurse implement?
A. Use an alcohol-based hand rub for 15 seconds.
B. Wash hands with non-antimicrobial soap and water.
C. Use a chlorhexidine gluconate solution for hand hygiene.
D. Wipe hands with a disposable germicidal wipe.
Answer: B
Rationale: C. difficile is a spore-forming bacterium that is resistant to alcohol-based hand
rubs. Washing hands with soap and water is required because the mechanical friction and
rinsing action are necessary to physically remove spores from the skin. Using alcohol-based
rubs or germicidal wipes is ineffective against these specific spores and can lead to cross-
contamination.
2. A nurse discovers a small fire in a client’s wastebasket. Which of the following actions
should the nurse take first?
A. Move the client to a safe area away from the fire.
B. Attempt to extinguish the fire using a fire extinguisher.
C. Close all doors and windows to contain the fire.
D. Activate the facility’s fire alarm system.
Answer: A
Rationale: According to the RACE acronym for fire safety, ‘R’ stands for Rescue/Remove,
which is always the first priority to ensure client safety. Activating the alarm (Alarm) and
containing the fire (Confine) are subsequent steps. Extinguishing the fire (Extinguish) is the
final step and should only be performed if it is safe to do so after all clients are secured.
3. A nurse is caring for a client who is post-operative and requires an intramuscular (IM)
injection. Which of the following sites is the safest for a large volume injection in an adult?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus lateralis
,Answer: B
Rationale: The ventrogluteal site is considered the safest and most preferred site for IM
injections in adults because it is located away from major nerves and blood vessels. The
dorsogluteal site is no longer recommended due to the proximity of the sciatic nerve. The
deltoid is used for small volumes, and while the vastus lateralis is safe, it is less preferred
than the ventrogluteal for large-volume injections in mobile adults.
4. A nurse is documenting in a client’s electronic health record. Which of the following entries
represents a professional and objective standard of documentation?
A. The client seems angry today and refused breakfast.
B. The client appears to be having a good day.
C. The client stated, ‘I feel frustrated because I cannot go home yet.’
D. The client was uncooperative during the physical exam.
Answer: C
Rationale: Documentation should be objective, factual, and avoid subjective
interpretations or judgmental language. Using a direct quote from the client provides an
accurate representation of their feelings without nurse bias. Terms like ‘seems,’ ‘appears,’
or ‘uncooperative’ are subjective and do not provide clear, measurable clinical data.
5. A nurse is caring for a client who is on airborne precautions. Which of the following
personal protective equipment (PPE) is essential for the nurse to wear?
A. Face shield
B. Surgical mask
C. N95 respirator
D. Gown and gloves only
Answer: C
Rationale: Airborne precautions are required for pathogens that remain suspended in the
air for long periods, such as tuberculosis or varicella. An N95 respirator is necessary to
filter out these small particles that a standard surgical mask cannot block. Surgical masks
are appropriate for droplet precautions, while gowns and gloves are standard for contact
precautions.
6. A nurse is assessing a client for orthostatic hypotension. Which of the following findings
indicates the client is experiencing this condition?
A. An increase in diastolic pressure of 5 mm Hg when sitting.
B. A decrease in systolic pressure of 20 mm Hg when standing.
C. An increase in heart rate of 5 beats per minute when standing.
, D. A decrease in systolic pressure of 5 mm Hg when sitting.
Answer: B
Rationale: Orthostatic hypotension is defined as a drop in systolic blood pressure of at
least 20 mm Hg or a drop in diastolic blood pressure of at least 10 mm Hg within 3 minutes
of standing. This occurs because the cardiovascular system fails to compensate for the
change in position. Minor changes in heart rate or small decreases in pressure are
considered normal physiological responses and do not meet the diagnostic criteria.
7. A nurse is providing teaching to a client about using a cane for ambulation. Which of the
following instructions should the nurse include?
A. Hold the cane on the weaker side of the body.
B. Hold the cane on the stronger side of the body.
C. Move the stronger leg forward first when walking.
D. Keep the elbow straight when holding the cane handle.
Answer: B
Rationale: To provide maximum support and balance, a cane should be held on the
unaffected (stronger) side. This allows the cane and the weaker leg to move forward
together, distributing weight evenly. The elbow should be slightly flexed (about 15 to 30
degrees), not straight, to allow for comfort and proper leverage during ambulation.
8. A nurse is caring for a client who is receiving enteral tube feedings. Which of the following
actions is the priority before administering the next feeding?
A. Flush the tube with 30 mL of warm water.
B. Warm the formula to room temperature.
C. Check the gastric residual volume.
D. Verify the placement of the tube.
Answer: D
Rationale: Verifying the tube placement is the highest priority to prevent aspiration, which
can occur if the tube has migrated to the lungs. Once placement is confirmed, checking
residual volume and flushing the tube are standard steps to ensure gastric emptying and
patency. While warming the formula is for comfort, it is not a safety priority compared to
preventing aspiration.
9. A nurse is teaching a client about a high-fiber diet. Which of the following food choices
should the nurse recommend?
A. White bread and canned fruit.
B. Peeled apples and white rice.
