RN VATI MIDTERM COMPREHENSIVE
STUDY GUIDE EXAM QUESTIONS AND
VERIFIED ANSWERS | 100% CORRECT |
GRADE A+
1. A nurse is caring for four clients. Which client should the nurse assess first using the ABC
(Airway, Breathing, Circulation) priority framework?
A. A client who is post-operative day 1 and reporting a pain level of 6/10.
B. A client with COPD who has an oxygen saturation of 91% on room air.
C. A client with Type 1 diabetes who has a blood glucose level of 150 mg/dL.
D. A client with heart failure who has developed sudden onset shortness of breath and
pink, frothy sputum.
Answer: D
Conceptual Explanation: Sudden onset of shortness of breath and pink frothy sputum are
classic signs of pulmonary edema, a life-threatening complication of heart failure requiring
immediate intervention to maintain breathing and oxygenation.
2. A nurse is monitoring a client in active labor and notes late decelerations on the fetal heart
rate (FHR) monitor. Which action is the priority?
A. Reposition the client to a lateral (side-lying) position.
,B. Increase the rate of the maintenance IV fluid infusion.
C. Perform a sterile vaginal examination to check for cord prolapse.
D. Administer oxygen at 8-10 L/min via non-rebreather mask.
Answer: A
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency. The
first action should be to improve blood flow to the placenta, which is best achieved by
moving the client off their back to a side-lying position.
3. A nurse is preparing to administer lithium carbonate to a client with bipolar disorder.
Which electrolyte abnormality should the nurse identify as increasing the risk for lithium
toxicity?
A. Hyponatremia
B. Hypercalcemia
C. Hypokalemia
D. Hypermagnesemia
Answer: A
Conceptual Explanation: Lithium is a salt; therefore, when sodium levels are low
(hyponatremia), the kidneys retain lithium in an attempt to maintain electrolyte balance,
leading to toxic levels.
, 4. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is therapeutic?
A. “I can hear the voices too, and they are telling you to relax.”
B. “I don’t hear the voices, but I understand they are real to you.”
C. “You should try to ignore the voices; they aren’t real anyway.”
D. “Why do you think the voices are talking to you right now?”
Answer: B
Conceptual Explanation: This response acknowledges the client’s experience without
validating the hallucination as reality, which helps build trust while maintaining a reality-
based perspective.
5. A 6-month-old infant is being treated for dehydration. Which of the following is the most
reliable indicator of the infant’s fluid volume status?
A. Skin turgor on the abdomen
B. Daily weights at the same time every day
C. The number of wet diapers in 24 hours
D. Mucous membrane moisture levels
Answer: B
Conceptual Explanation: In pediatrics, daily weight is the most objective and accurate
measure of fluid loss or gain.
STUDY GUIDE EXAM QUESTIONS AND
VERIFIED ANSWERS | 100% CORRECT |
GRADE A+
1. A nurse is caring for four clients. Which client should the nurse assess first using the ABC
(Airway, Breathing, Circulation) priority framework?
A. A client who is post-operative day 1 and reporting a pain level of 6/10.
B. A client with COPD who has an oxygen saturation of 91% on room air.
C. A client with Type 1 diabetes who has a blood glucose level of 150 mg/dL.
D. A client with heart failure who has developed sudden onset shortness of breath and
pink, frothy sputum.
Answer: D
Conceptual Explanation: Sudden onset of shortness of breath and pink frothy sputum are
classic signs of pulmonary edema, a life-threatening complication of heart failure requiring
immediate intervention to maintain breathing and oxygenation.
2. A nurse is monitoring a client in active labor and notes late decelerations on the fetal heart
rate (FHR) monitor. Which action is the priority?
A. Reposition the client to a lateral (side-lying) position.
,B. Increase the rate of the maintenance IV fluid infusion.
C. Perform a sterile vaginal examination to check for cord prolapse.
D. Administer oxygen at 8-10 L/min via non-rebreather mask.
Answer: A
Conceptual Explanation: Late decelerations indicate uteroplacental insufficiency. The
first action should be to improve blood flow to the placenta, which is best achieved by
moving the client off their back to a side-lying position.
3. A nurse is preparing to administer lithium carbonate to a client with bipolar disorder.
Which electrolyte abnormality should the nurse identify as increasing the risk for lithium
toxicity?
A. Hyponatremia
B. Hypercalcemia
C. Hypokalemia
D. Hypermagnesemia
Answer: A
Conceptual Explanation: Lithium is a salt; therefore, when sodium levels are low
(hyponatremia), the kidneys retain lithium in an attempt to maintain electrolyte balance,
leading to toxic levels.
, 4. A nurse is caring for a client with schizophrenia who is experiencing auditory
hallucinations. Which response by the nurse is therapeutic?
A. “I can hear the voices too, and they are telling you to relax.”
B. “I don’t hear the voices, but I understand they are real to you.”
C. “You should try to ignore the voices; they aren’t real anyway.”
D. “Why do you think the voices are talking to you right now?”
Answer: B
Conceptual Explanation: This response acknowledges the client’s experience without
validating the hallucination as reality, which helps build trust while maintaining a reality-
based perspective.
5. A 6-month-old infant is being treated for dehydration. Which of the following is the most
reliable indicator of the infant’s fluid volume status?
A. Skin turgor on the abdomen
B. Daily weights at the same time every day
C. The number of wet diapers in 24 hours
D. Mucous membrane moisture levels
Answer: B
Conceptual Explanation: In pediatrics, daily weight is the most objective and accurate
measure of fluid loss or gain.
