VATI Greenlight STUDY TEST A nurse is caring for a client who had a partial laryngectomy and is receiving continuous enteral feedings at 65 mL/hr through a gastrostomy tube. Which of the following findings requires immediate intervention by the nurse? A nurse is assessing a client who has a magnesi...
VATI RN GREENLIGHT EXAM
A nurse is planning care for a client who has a new diagnosis of HIV. Which of the following client
statements should the nurse address first? Correct Answer: I can't seem to gain any weight
A nurse is performing disaster triage following a natural disaster. Which of the following should the
nurse identify as the highest priority to receive care? Correct Answer: A client who has agonal
respirations
A nurse is caring for a client who reports chest pain. Which of the following laboratory findings indicates
myocardial damage? Correct Answer: Troponin I 1.8 ng/mL
A nurse is providing teaching to the parent of a child who has pediculosis capitis. Which of the following
information should be included in the teaching? Correct Answer: Store nonwashable items in plastic
bags for 14 days
A nurse is assessing a client who is 8 hr postoperative following a right-modified radical mastectomy.
Which of the following should the nurse recognize as the priority finding? Correct Answer: Coughing
frothy, pink secretions
A nurse in a newborn nursery is performing assessments on four neonates that are all less than 24 hr
old. The nurse should plan to notify the provider of which of the following findings? Correct Answer:
Pinna below the outer canthus of the eye
An assistive personnel tells the nurse that several client measurements were obtained with morning
vital signs. Which of the following clients should the nurse plan to assess first? Correct Answer: A 4-
year-old who has closed head injury and a heart rate of 60/min
A nurse is planning the discharge of an infant who has tetralogy of Fallot. The nurse anticipates the need
for which of the following equipment? Correct Answer: Pulse oximeter
A home health nurse is assessing a client who is recovering from an acute myocardial infarction (MI).
Which of the following assessment findings should the nurse report to the provider as a possible
indication of left-sided heart failure? Correct Answer: Bilateral lung crackles
A nurse is performing a nutritional assessment on a client who has a calcium deficiency. The nurse
should identify that the client is at risk for which of the following? Correct Answer: Osteogenesis
A nurse is caring for a client who was involuntarily admitted to the psychiatric unit following a failed
suicide attempt. The provider prescribes a medication that is part of an experimental treatment. Which
of the following actions should the nurse take? Correct Answer: Witness consent before medication
administration
A nurse is providing education to the mother of a toddler who has pertussis. Which of the following
statements by the parent indicates the teaching has been effective? Correct Answer: If I get pregnant, I
should check with my provider about receiving a pertussis booster
,A school nurse is assessing a child who has scabies. Which of the following is an expected finding?
Correct Answer: Red, itchy papules on child's groin area
A nurse is caring for a client who is at risk for developing diabetes insipidus (DI) following a severe head
injury. Which assessment finding indicates to the nurse that the client is developing DI? Correct Answer:
Urine output 250 mL/hr
A nurse is caring for a client who is 2 hr postoperative following an ileal conduit procedure for bladder
cancer. For which of the following findings should the nurse notify the provider? Correct Answer: A
dusky-colored stoma
A nurse on the orthopedic floor is completing the morning assessments on several clients. Which of the
following clients has the greatest risk for fat embolism syndrome (FES)? Correct Answer: A 24-year- old
male who has a casted femur fracture
A nurse in the clinic is providing information to a client who has mastitis of left breast. The client asks
the nurse, Does this mean that I must stop nursing my baby?" Which of the following is an appropriate
statement by the nurse? Correct Answer: No, you can continue to nurse from both your breasts
A nurse is reviewing morning laboratory values for several clients. Which of the following findings is the
highest priority for the nurse to report to the provider? Correct Answer: A client who is prescribed
digoxin and furosemide and has a potassium level of 3.1 mEq/L
A nurse is preparing to provide education about electroconvulsive therapy (ECT) for a client who has
major depressive disorder. Which of the following should the nurse include in the teaching? Correct
Answer: A general anesthetic administered prior to ECT treatments
A nurse is teaching a client who has left-leg weakness how to use a standard walker. Which of the
following actions by the client indicates a need for further teaching? Correct Answer: Moves the left leg
and walker ahead together
A nurse is teaching a client who has left-leg weakness how to use a standard walker. Which of the
following actions by the client indicates a need for further teaching? Correct Answer: Places the walker
2 feet forward with each step
A nurse is caring for a client who has a diagnosis of antisocial personality disorder. The nurse should
expect the client to demonstrate which of the following? Correct Answer: Poor impulse control
A home health nurse is reviewing treatment goals with a client who has diabetes mellitus. The nurse
should evaluate which of the following laboratory tests to determine effective long-term management
of blood glucose levels? Correct Answer: HbA1c
A nurse is planning care for a client who takes haloperidol for the treatment of schizophrenia. Which of
the following should the nurse include in the plan of care? Correct Answer: Screen the client for tardive
dyskinesia
,A nurse is evaluating the results of the above urinalysis done for a preschool age child. The nurse should
identify that these findings are consistent with which of the following renal disorders? Correct Answer:
Pyelonephritis
At the beginning of the day shift, a team leader delegates the following tasks to the assistive personnel
(AP): bathe four clients, distribute fresh water, obtain morning vital signs. At noon, the nurse asks the AP
to transport one client to physical therapy. The AP reports two clients still need baths. Which of the
following is an appropriate strategy for the nurse to delegate more effectively in the future? Correct
Answer: Set a clear time frame for the completion of each task
A nurse is caring for a client who has a hearing impairment. When speaking to the client, the nurse
should incorporate which communication methods? Correct Answer: Rephrase sentences the client
does not understand
A nurse is discussing the Z-track administration of hydroxyzine hydrochloride with a newly licensed
nurse. Which of the following statements indicates the newly licensed nurse understands the purpose of
the technique? Correct Answer: This technique decreases the risk of subcutaneous infiltration
A nurse is reviewing medical records for four clients. Which of the following represents appropriate
documentation? Correct Answer: Lovenox 30 mg SC every 12 hr
A nurse is performing postmortem care on an older adult client. Which of the following actions is
appropriate to take? Correct Answer: Place absorbent pads under the buttocks area
A nurse is discussing a living will with a client. Which of the following statement indicates an
understanding of this document? Correct Answer: It communicates my wishes for end-of-life care
A nurse on a medical-surgical unit is caring for a group of clients. Which of the following clients would
benefit from a three-way indwelling catheter? Correct Answer: A female client who is prone to
development of blood clots in the urine
A nurse is planning dietary intervention for a client who is immobile due to pelvic and femur fractures.
Which of the following should the nurse include in the plan? Correct Answer: Provide a high-protein
diet
A nurse is assessing a client who is preparing for surgery. The client tells the nurse, "If something
happens to me from which I cannot recover, I don't want to go on a ventilator." Which of the following
is an appropriate response by the nurse? Correct Answer: You're concerned that something may go
wrong?
A nurse manager at a public health clinic is concerned about the rising number of sexually transmitted
infections in the community. The purpose of which of the following is to generate new ideas to address
the public health concern? Correct Answer: A brainstorming session with nurses
A nurse is planning care for a client who has neutropenia. Which of the following nursing interventions is
appropriate to include in the care plan? Correct Answer: Remove fresh flowers from the clients room
, A nurse is planning to admit a client who has hyperthyroidism. Which of the following rooms is
appropriate for the nurse to assign this client to? Correct Answer: A room near the nurse's station
A nurse is caring for a client who is experiencing acute mania. Which of the following actions should the
nurse include in the plan of care? Correct Answer: Provide high-calorie nutritional supplements
A nurse is preparing to provide discharge teaching to a client who has an ileal conduit due to treatment
for bladder cancer. Which of the following instructions should the nurse include in the teaching? Correct
Answer: Rinse the reusable pouch with hot water
A nurse is providing teaching to an adolescent who has cystic fibrosis and has a prescription for
pancrelipase. Which of the following should the nurse include in the teaching? Correct Answer: Take
with meals
A nurse is planning to provide community education about viral hepatitis. Which of the following should
the nurse plan to include in the teaching Correct Answer: Clients who have a history of viral hepatitis
are unable to donate blood
An AP at a long-term care facility reports to the nurse that another AP has spent the entire morning on
the phone and has not completed the morning assignment. Which of the following is an appropriate
action by the nurse? Correct Answer: Ask the AP what work remains to be completed on the
assignment
A nurse is caring for a client who is receiving enteral nutrition. Which of the following indicates a need to
decrease the rate of the enteral feeding? Correct Answer: Poor skin turgor
A nurse in a prenatal clinic is caring for an adolescent client who is in her third trimester of pregnancy.
The nurse identifies that the client is at an increased risk for which of the following? Correct Answer:
Postpartum depression
A nurse is caring for a group of clients. The nurse should request a referral for a speech language
pathologist for which of the following clients? Correct Answer: A client who has difficulty swallowing
A nurse is caring for a client who is prescribed furosemide. The nurse understands this medication is
used to treat which of the following client conditions? Correct Answer: Rales in lower lobes of lungs
A nurse is admitting an infant who has bacterial meningitis. Which of the following actions should the
nurse take first? Correct Answer: Minimize environmental stimuli
A nurse is caring for a client who has cirrhosis of the liver. Which of the following actions by the nurse is
appropriate? Correct Answer: Monitor for abdominal ascites
A nurse is caring for a client who reports difficulty falling asleep at night. Which of the following
suggestions should the nurse recommend? Correct Answer: Eat a bedtime snack containing
carbohydrates
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