vati finals
1. b. Platelet count 90,000/mm2: A nurse is reviewing the laboratory results for a client
who is at 32 gestations. For which of the following results should the nurse notify the
provider?
a. Hgb 12 g/dL
b.Platelet count 90,000/mm2
c. Hematocrit 37%
d. Creatinine 0.7 mg/dl
2. b. A client who has heart failure and reports severe dyspnea: After receiving
change-of-shift report, which of the following clients should the nurse collect data from
first? a. A client who has a history of pancreatitis and reports severe abdominal pain b. A
client who has heart failure and reports severe dyspnea c. A client who is scheduled for
abdominal surgery in 1 hrs d. A postoperative client who has diabetes mellitus and a blood
glucose of 280 mg/dK
3. b. Contact security personnel to place the money in the facility safe: A nurse is
preparing a client for surgery. The client tells the nurse that he is concerned about the
safety of a large sum of money in his wallet. Which of the following actions is appropriate
for the nurse to take?
a. Place the money in an envelope and lock it in the client's medication drawer
b. Contact security personnel to place the money in the facility safe c. Hold the money
for the client until he returns from surgery
d. Label the money and leave it with the unit secretary.
4. c. Pull the auricle upward and backward.: A nurse is preparing to instill an optic
suspension into an adult client' ear. Which of the following methods should the nurse plan
to use?
a. Pull the auricle upward and outward.
b.Pull the auricle downward and backward.
c. Pull the auricle upward and backward.
d. Pull the auricle downward an outward
5. b. Increased elasticity of the thoracic cage: 5. A nurse is caring for an older adult
client who has pneumonia. When reinforcing teaching about the diagnosis age- related
changes with the client's family, which of the following alterations should the nurse
include?
a. Increased inflation of the basilar lungs
b.Increased elasticity of the thoracic cage
c. Hypertrophy of the bronchial mucous gland
d. Hyperactive cough reflex
6. b. Rationalism: A client is participating in an anger management session explain that
his recent behavior is related to his job loss. Which of the following mechanism is the
client using?
, vati finals
a. Projection
b.Rationalism
c. Repression
d. Sublimation
7. c. "I will have the chest x-ray following the procedure.": A nurse is reinforcing
teaching with the client who is about to undergo a thoracentesis. Which if the following
statement by the client indicates an understanding of the information?
a. "I will have general anesthesia during the procedure."
b."I will lie flat for 6 hours before the procedure."
c. "I will have the chest x-ray following the procedure."
d. "I will breathe deeply through my nose during the procedure.
8. a. History of renal calculi: A nurse is reviewing the medical record of a client who is
requesting an oral contraceptive. Which of the following findings should the nurse
identify as a contraindication to the use of oral contraceptive? a. History of renal calculi
b. Migraines with aura
c. BMI of 26
d. History of cholecystectomy
9. a. Avoid sharing razors with other family members.: . A nurse is reinforcing
discharge teaching about transmission precautions with a client who has Hepatitis
C. Which of the following information should the nurse include?
a. Avoid sharing razors with other family members.
b.clean toilet surfaces with bleach after each use
c. Advice family members to receive a hepatitis c immunization
d. Do not prepare food for other family member s while infectious
10.c. Dispose of the used needle immediately in a puncture proof sharps container.:
A nurse is preparing to administer an IM injection to a client. To reduce the risk of a
needle stick injury, the nurse should take which of the following actions?
a. Place a cap holds securely on the used needle a before disposal. b. Recap the needle
using a one-handed scoop approach before proper disposal.
c. Dispose of the used needle immediately in a puncture proof sharps container.
d. Detach and dispose of the use needle promptly following injection
11.c. "I need to take this medication for the rest of my life.": A nurse is reinforcing
teaching with a client who has new prescription for levothyroxine. Which of the following
statements indicates understanding of the instructions?
a. "I should take this medication with meals."
b.This medication will take 2 weeks to reach full effectiveness."
c. "I need to take this medication for the rest of my life."
d. "If I forget to take the medication, I can double the next dose."
, vati finals
12.c. Instruct the client to stand up slowly: A nurse is caring for a client who is
receiving prazosin. The client's blood pressure is 100/60 mm Hg. which of the
following actions should the nurse take?
a. Administer a reversal agent
b.Initiate cardiac monitoring
c. Instruct the client to stand up slowly
d. Inform the client to report urinary retention
13.d. I will empty the colostomy bag when one half is full: A nurse is reinforcing
teaching about colostomy care with a client. Which of the following client statements
indicate an understanding of how to care for the colostomy?
a. I will cleanse the stoma site gently with an antiseptic solution.
b.I will contact my doctor right away if my stoma is red
c. I will cut the water opening 1 inch bigger than my stoma.
d. I will empty the colostomy bag when one half is full
14.b. "I need to record my pulse rate daily.": A nurse is reinforcing teaching with a
client who has a permanent pacemaker in place. Which of the following statements by the
client indicates an understanding of the teaching?
a. "I should have my doctor replace the battery in the pacemaker in a year."
b."I need to record my pulse rate daily."
c. "I should avoid taking tub baths."
d. "I will remove my microwave oven from my house."
15.c. Long-term use of immunosuppressants: A nurse is collecting data from a
parent of a preschooler at a well-child visit. Which of the following findings is a
contraindication to a measles, mumps and rubella (MMR) immunization?
a. Family history of allergies to penicillin
b.Erythema at injection site with previous immunization.
c. Long-term use of immunosuppressants
d. Current use of antimicrobial therapy.
16.b. 1 cup raw broccoli: . A nurse is reinforcing teaching with a client who has a
vitamin C deficiency. Which of the following foods should the nurse include as having the
highest vitamin C content?
a. 1 cup yogurt
b.1 cup raw broccoli
c. 1 large baked potato
d. 1 cup boiled carrots
17.a. The television set is turned to a loud volume: A nurse is checking the home
environment of a client for safety hazards. Which of the following items require
intervention by the nurse?
a.The television set is turned to a loud volume
, vati finals
b.The dining room table has low chairs with no armrests
c.The bedroom extension cord is placed under a heavy nightstand
d.The living room contains wall to wall carpeting.
18.a. Have the client's older sibling give consent if parent is not available.: 18. A
nurse is caring for a 17-yr. old client who is admitted for an emergency appen- dectomy.
Which of the following is an appropriate action by the nurse in obtaining informed
consent?
a. Have the client's older sibling give consent if parent is not available.
b.Delay the procedure if the provider cannot contact the parents.
c.Witness the signature of the client's parents when he arrives.
d. Obtain verbal consent from the client while waiting for the parents to arrive
19.b. Graham crackers: A nurse is reinforcing teaching with a parent about appro- priate
snacks for a toddler. Which of the following food should the nurse include?
a. Marshmallows
b.Graham crackers
c. Almonds
d. Carrot sticks
20.a. Right after the client void: A nurse is preparing to catheterize a client's bladder
to check for residual urine. The nurse should schedule this procedure at which of the
following times?
a. Right after the client void
b.When the client feels an urge to void
c.While voiding on a bedpan
d. Before obtaining a bladder scan.
21.a. Place the client in a private room: A nurse is caring for a client who has viral
pneumonia. Which of the following actions should the nurse take?
a. Place the client in a private room
b.Administer azithromycin
c. Recommend a pneumococcal immunization.
d. Limit fluid intake to 1L per day
22.b. Kussmaul respirations: 22. A nurse is collecting data from a client who has
diabetes mellitus. Which of the following indicates the client might be experiencing
diabetic ketoacidosis?
a. Negative urine ketones
b.Kussmaul respirations
c. Hypoglycemia
d. Anuria
23.a. Check client's vital signs.: A nurse receives a verbal order for a client to receive
a stat dose of meperidine 100 mg PO. She administers the medication,
1. b. Platelet count 90,000/mm2: A nurse is reviewing the laboratory results for a client
who is at 32 gestations. For which of the following results should the nurse notify the
provider?
a. Hgb 12 g/dL
b.Platelet count 90,000/mm2
c. Hematocrit 37%
d. Creatinine 0.7 mg/dl
2. b. A client who has heart failure and reports severe dyspnea: After receiving
change-of-shift report, which of the following clients should the nurse collect data from
first? a. A client who has a history of pancreatitis and reports severe abdominal pain b. A
client who has heart failure and reports severe dyspnea c. A client who is scheduled for
abdominal surgery in 1 hrs d. A postoperative client who has diabetes mellitus and a blood
glucose of 280 mg/dK
3. b. Contact security personnel to place the money in the facility safe: A nurse is
preparing a client for surgery. The client tells the nurse that he is concerned about the
safety of a large sum of money in his wallet. Which of the following actions is appropriate
for the nurse to take?
a. Place the money in an envelope and lock it in the client's medication drawer
b. Contact security personnel to place the money in the facility safe c. Hold the money
for the client until he returns from surgery
d. Label the money and leave it with the unit secretary.
4. c. Pull the auricle upward and backward.: A nurse is preparing to instill an optic
suspension into an adult client' ear. Which of the following methods should the nurse plan
to use?
a. Pull the auricle upward and outward.
b.Pull the auricle downward and backward.
c. Pull the auricle upward and backward.
d. Pull the auricle downward an outward
5. b. Increased elasticity of the thoracic cage: 5. A nurse is caring for an older adult
client who has pneumonia. When reinforcing teaching about the diagnosis age- related
changes with the client's family, which of the following alterations should the nurse
include?
a. Increased inflation of the basilar lungs
b.Increased elasticity of the thoracic cage
c. Hypertrophy of the bronchial mucous gland
d. Hyperactive cough reflex
6. b. Rationalism: A client is participating in an anger management session explain that
his recent behavior is related to his job loss. Which of the following mechanism is the
client using?
, vati finals
a. Projection
b.Rationalism
c. Repression
d. Sublimation
7. c. "I will have the chest x-ray following the procedure.": A nurse is reinforcing
teaching with the client who is about to undergo a thoracentesis. Which if the following
statement by the client indicates an understanding of the information?
a. "I will have general anesthesia during the procedure."
b."I will lie flat for 6 hours before the procedure."
c. "I will have the chest x-ray following the procedure."
d. "I will breathe deeply through my nose during the procedure.
8. a. History of renal calculi: A nurse is reviewing the medical record of a client who is
requesting an oral contraceptive. Which of the following findings should the nurse
identify as a contraindication to the use of oral contraceptive? a. History of renal calculi
b. Migraines with aura
c. BMI of 26
d. History of cholecystectomy
9. a. Avoid sharing razors with other family members.: . A nurse is reinforcing
discharge teaching about transmission precautions with a client who has Hepatitis
C. Which of the following information should the nurse include?
a. Avoid sharing razors with other family members.
b.clean toilet surfaces with bleach after each use
c. Advice family members to receive a hepatitis c immunization
d. Do not prepare food for other family member s while infectious
10.c. Dispose of the used needle immediately in a puncture proof sharps container.:
A nurse is preparing to administer an IM injection to a client. To reduce the risk of a
needle stick injury, the nurse should take which of the following actions?
a. Place a cap holds securely on the used needle a before disposal. b. Recap the needle
using a one-handed scoop approach before proper disposal.
c. Dispose of the used needle immediately in a puncture proof sharps container.
d. Detach and dispose of the use needle promptly following injection
11.c. "I need to take this medication for the rest of my life.": A nurse is reinforcing
teaching with a client who has new prescription for levothyroxine. Which of the following
statements indicates understanding of the instructions?
a. "I should take this medication with meals."
b.This medication will take 2 weeks to reach full effectiveness."
c. "I need to take this medication for the rest of my life."
d. "If I forget to take the medication, I can double the next dose."
, vati finals
12.c. Instruct the client to stand up slowly: A nurse is caring for a client who is
receiving prazosin. The client's blood pressure is 100/60 mm Hg. which of the
following actions should the nurse take?
a. Administer a reversal agent
b.Initiate cardiac monitoring
c. Instruct the client to stand up slowly
d. Inform the client to report urinary retention
13.d. I will empty the colostomy bag when one half is full: A nurse is reinforcing
teaching about colostomy care with a client. Which of the following client statements
indicate an understanding of how to care for the colostomy?
a. I will cleanse the stoma site gently with an antiseptic solution.
b.I will contact my doctor right away if my stoma is red
c. I will cut the water opening 1 inch bigger than my stoma.
d. I will empty the colostomy bag when one half is full
14.b. "I need to record my pulse rate daily.": A nurse is reinforcing teaching with a
client who has a permanent pacemaker in place. Which of the following statements by the
client indicates an understanding of the teaching?
a. "I should have my doctor replace the battery in the pacemaker in a year."
b."I need to record my pulse rate daily."
c. "I should avoid taking tub baths."
d. "I will remove my microwave oven from my house."
15.c. Long-term use of immunosuppressants: A nurse is collecting data from a
parent of a preschooler at a well-child visit. Which of the following findings is a
contraindication to a measles, mumps and rubella (MMR) immunization?
a. Family history of allergies to penicillin
b.Erythema at injection site with previous immunization.
c. Long-term use of immunosuppressants
d. Current use of antimicrobial therapy.
16.b. 1 cup raw broccoli: . A nurse is reinforcing teaching with a client who has a
vitamin C deficiency. Which of the following foods should the nurse include as having the
highest vitamin C content?
a. 1 cup yogurt
b.1 cup raw broccoli
c. 1 large baked potato
d. 1 cup boiled carrots
17.a. The television set is turned to a loud volume: A nurse is checking the home
environment of a client for safety hazards. Which of the following items require
intervention by the nurse?
a.The television set is turned to a loud volume
, vati finals
b.The dining room table has low chairs with no armrests
c.The bedroom extension cord is placed under a heavy nightstand
d.The living room contains wall to wall carpeting.
18.a. Have the client's older sibling give consent if parent is not available.: 18. A
nurse is caring for a 17-yr. old client who is admitted for an emergency appen- dectomy.
Which of the following is an appropriate action by the nurse in obtaining informed
consent?
a. Have the client's older sibling give consent if parent is not available.
b.Delay the procedure if the provider cannot contact the parents.
c.Witness the signature of the client's parents when he arrives.
d. Obtain verbal consent from the client while waiting for the parents to arrive
19.b. Graham crackers: A nurse is reinforcing teaching with a parent about appro- priate
snacks for a toddler. Which of the following food should the nurse include?
a. Marshmallows
b.Graham crackers
c. Almonds
d. Carrot sticks
20.a. Right after the client void: A nurse is preparing to catheterize a client's bladder
to check for residual urine. The nurse should schedule this procedure at which of the
following times?
a. Right after the client void
b.When the client feels an urge to void
c.While voiding on a bedpan
d. Before obtaining a bladder scan.
21.a. Place the client in a private room: A nurse is caring for a client who has viral
pneumonia. Which of the following actions should the nurse take?
a. Place the client in a private room
b.Administer azithromycin
c. Recommend a pneumococcal immunization.
d. Limit fluid intake to 1L per day
22.b. Kussmaul respirations: 22. A nurse is collecting data from a client who has
diabetes mellitus. Which of the following indicates the client might be experiencing
diabetic ketoacidosis?
a. Negative urine ketones
b.Kussmaul respirations
c. Hypoglycemia
d. Anuria
23.a. Check client's vital signs.: A nurse receives a verbal order for a client to receive
a stat dose of meperidine 100 mg PO. She administers the medication,
