PN VATI FUNDAMENTALS
2020
1. Thirst.
Rationale:
Thirst, combined with an elevated temperature and a lack of sweating, can be an
indication of hypernatremia.: A nurse is collecting data from a client who has an
elevated temperature with no sweating. Which of the following findings is an indication of
hypernatremia?
Thirst
Muscle twitching
Headache
Abdominal cramps
2. Close the door to the client's room.
Rationale:
The nurse should close the door to the client's room whenever possible to reduce
environmental noise.: A nurse is caring for a client who reports difficulty sleeping due to
the noise on the nursing unit. Which of the following actions should the nurse take to
reduce environmental noise?
Close the door to the client's room.
Turn off the alarms and beeps on monitoring equipment.
Conduct change-of-shift report outside the client's door. Keep
the television on low in the client's room.
3. Identify areas of concern.
Rationale:
The first action the nurse should take when using the nursing process is to collect
data from the client. Identifying and understanding the client's
concerns prior to reinforcing teaching promotes effective learning.: A nurse is
reinforcing teaching about health promotion with a client. Which of the following actions
should the nurse take first to promote effective learning?
Identify areas of concern. Prioritize
learning objectives. Demonstrate
psychomotor skills.
Observe nonverbal communication.
4. Clarify the role of this individual nurse.
, PN VATI FUNDAMENTALS
2020
Rationale:
The nurse should plan to establish a warm, caring relationship while clarifying the
role of each participant, which occurs during the orientation phase of the
relationship.: A home health nurse is assisting with the plan of care for a client.
Which of the following should the nurse include during the orientation phase of the
helping relationship?
Review current client data.
Assist to meet client goals.
Review shared memories of interactions with client.
Clarify the role of this individual nurse.
5. The wheel locks on the bed are malfunctioning.
Rationale:
The greatest risk to this client is injury from a fall when getting into or out of a bed
that is unstable due to malfunctioning locks. Therefore, the priority is to report and
replace the bed before admitting the client to the room.: A nurse is preparing to assist
with the admission of a client who has pneumonia. Which of the following observations
about the client's room requires immediate attention?
The wall BP gauge is missing.
The room has no IV infusion pump.
The examination light above the bed does not work. The
wheel locks on the bed are malfunctioning.
6. Participate in screenings for tuberculosis.
Rationale:
The nurse should encourage the client to participate in screenings for tuber- culosis,
a secondary prevention measure. Secondary prevention measures focus on diagnosis
and early intervention.: A nurse is reinforcing teaching about health promotion with an
older adult client. Which of the following instructions to the client is an example of
secondary prevention?
Participate in screenings for tuberculosis.
Follow dietary recommendations to reduce the risk for osteoporosis. Limit
alcohol intake to one drink per day.
Perform yoga exercises three times per week.
7. Staging a pressure ulcer.
, PN VATI FUNDAMENTALS
2020
Rationale:
An LPN can collect data for the client and report findings to an RN. However,
staging a pressure ulcer requires advance knowledge and skill, and is outside the
scope of practice of an LPN. An RN should assess the stage of a complex wound, such
as a pressure ulcer, and provide primary client teaching about pressure ulcer
prevention and care.: A licensed practical nurse (LPN) is receiving change-of-shift report
for a client who had a stroke. For which of the following tasks should the nurse request
assistance from a registered nurse (RN)?
Administering a cleansing enema
Staging a pressure ulcer
Inserting an indwelling urinary catheter
Performing passive range-of-motion exercises
8. "I will secure all of my electrical cords to the baseboard."
Rationale:
Securing cords along the baseboards with electrical tape minimizes the trip- ping
hazard for clients who are at risk for falls.: A nurse is reinforcing teaching about home
safety with a client who is at risk for falls. Which of the following client statements
indicates an understanding of the teaching?
"I will keep my floors well waxed."
"I will take my shoes off when I come back into the house." "I
will secure all of my electrical cords to the baseboard."
"I will place area rugs on my tile floors."
9. "I will wash my hands with soap and water for 15 seconds after having a
bowel movement."
Rationale:
The nurse should inform the client to wash their hands with soap and warm water
for 15 seconds to remove micro-organisms after having a bowel move- ment. This
reduces the risk for transmitting the virus to others because he- patitis A is a virus
that is transmitted via the oral-fecal route.: A home health nurse is reinforcing teaching
about infection control with a client who has hepatitis
A. The nurse should identify that which of the following client statements indicates an
understanding of the teaching?
"I will use a 10 to 1 solution of soap and water to clean my bathroom fixtures." "I
will wear a surgical mask when around others."
2020
1. Thirst.
Rationale:
Thirst, combined with an elevated temperature and a lack of sweating, can be an
indication of hypernatremia.: A nurse is collecting data from a client who has an
elevated temperature with no sweating. Which of the following findings is an indication of
hypernatremia?
Thirst
Muscle twitching
Headache
Abdominal cramps
2. Close the door to the client's room.
Rationale:
The nurse should close the door to the client's room whenever possible to reduce
environmental noise.: A nurse is caring for a client who reports difficulty sleeping due to
the noise on the nursing unit. Which of the following actions should the nurse take to
reduce environmental noise?
Close the door to the client's room.
Turn off the alarms and beeps on monitoring equipment.
Conduct change-of-shift report outside the client's door. Keep
the television on low in the client's room.
3. Identify areas of concern.
Rationale:
The first action the nurse should take when using the nursing process is to collect
data from the client. Identifying and understanding the client's
concerns prior to reinforcing teaching promotes effective learning.: A nurse is
reinforcing teaching about health promotion with a client. Which of the following actions
should the nurse take first to promote effective learning?
Identify areas of concern. Prioritize
learning objectives. Demonstrate
psychomotor skills.
Observe nonverbal communication.
4. Clarify the role of this individual nurse.
, PN VATI FUNDAMENTALS
2020
Rationale:
The nurse should plan to establish a warm, caring relationship while clarifying the
role of each participant, which occurs during the orientation phase of the
relationship.: A home health nurse is assisting with the plan of care for a client.
Which of the following should the nurse include during the orientation phase of the
helping relationship?
Review current client data.
Assist to meet client goals.
Review shared memories of interactions with client.
Clarify the role of this individual nurse.
5. The wheel locks on the bed are malfunctioning.
Rationale:
The greatest risk to this client is injury from a fall when getting into or out of a bed
that is unstable due to malfunctioning locks. Therefore, the priority is to report and
replace the bed before admitting the client to the room.: A nurse is preparing to assist
with the admission of a client who has pneumonia. Which of the following observations
about the client's room requires immediate attention?
The wall BP gauge is missing.
The room has no IV infusion pump.
The examination light above the bed does not work. The
wheel locks on the bed are malfunctioning.
6. Participate in screenings for tuberculosis.
Rationale:
The nurse should encourage the client to participate in screenings for tuber- culosis,
a secondary prevention measure. Secondary prevention measures focus on diagnosis
and early intervention.: A nurse is reinforcing teaching about health promotion with an
older adult client. Which of the following instructions to the client is an example of
secondary prevention?
Participate in screenings for tuberculosis.
Follow dietary recommendations to reduce the risk for osteoporosis. Limit
alcohol intake to one drink per day.
Perform yoga exercises three times per week.
7. Staging a pressure ulcer.
, PN VATI FUNDAMENTALS
2020
Rationale:
An LPN can collect data for the client and report findings to an RN. However,
staging a pressure ulcer requires advance knowledge and skill, and is outside the
scope of practice of an LPN. An RN should assess the stage of a complex wound, such
as a pressure ulcer, and provide primary client teaching about pressure ulcer
prevention and care.: A licensed practical nurse (LPN) is receiving change-of-shift report
for a client who had a stroke. For which of the following tasks should the nurse request
assistance from a registered nurse (RN)?
Administering a cleansing enema
Staging a pressure ulcer
Inserting an indwelling urinary catheter
Performing passive range-of-motion exercises
8. "I will secure all of my electrical cords to the baseboard."
Rationale:
Securing cords along the baseboards with electrical tape minimizes the trip- ping
hazard for clients who are at risk for falls.: A nurse is reinforcing teaching about home
safety with a client who is at risk for falls. Which of the following client statements
indicates an understanding of the teaching?
"I will keep my floors well waxed."
"I will take my shoes off when I come back into the house." "I
will secure all of my electrical cords to the baseboard."
"I will place area rugs on my tile floors."
9. "I will wash my hands with soap and water for 15 seconds after having a
bowel movement."
Rationale:
The nurse should inform the client to wash their hands with soap and warm water
for 15 seconds to remove micro-organisms after having a bowel move- ment. This
reduces the risk for transmitting the virus to others because he- patitis A is a virus
that is transmitted via the oral-fecal route.: A home health nurse is reinforcing teaching
about infection control with a client who has hepatitis
A. The nurse should identify that which of the following client statements indicates an
understanding of the teaching?
"I will use a 10 to 1 solution of soap and water to clean my bathroom fixtures." "I
will wear a surgical mask when around others."
