RN VATI Fundamentals Assessment
1. A nurse is preparing 1: Draw up the volume of insulin from the interme-
to mix short-acting and diate-acting insulin vial.
intermediate-acting in-
sulin in one syringe to 2: Inject the volume of air equal to the amount
administer to a client of insulin to withdraw from the intermediate-acting
who has type 1 diabetes insulin vial.
mellitus. Identify the se-
quence the nurse should 3: Inject the volume of air equal to the insulin dose
follow. form the short-acting insulin vial
4: Withdraw the prescribed amount of insulin form
the short-acting insulin vial.
5: Withdraw the prescribed amount of insulin form
the intermediate-acting insulin vial.
To mix insulin from two vials in the same syringe,
the nurse should first draw up a volume of air
equal to the volume of insulin from the intermedi-
ate-acting insulin vial. The nurse should then inject
the volume of air equal to the amount of insulin
to withdraw from the intermediate-acting insulin
vial, making sure the needle does not touch the
insulin. Next, the nurse should inject the volume of
air equal to the insulin dose from the short-acting
insulin vial. Then, the nurse should withdraw the
prescribed amount of insulin from the short-acting
insulin vial. Lastly, the nurse should withdraw the
prescribed amount of insulin from the intermedi-
ate-acting insulin vial. The insulins are now mixed
and ready to administer.
2. A nurse is assessing a Advise the client to rinse their mouth and dentures
client who wears par- after each meal.
tial dentures and reports
mouth pain. Which of the The nurse should advise the client to rinse their
following actions should mouth and dentures after each meal to remove
the nurse take? food and particles and to promote healing of gums
and oral mucosa.
,RN VATI Fundamentals Assessment
The nurse should instruct the client to rinse their
mouth four times each day with mild rinses, such
as normal saline or sodium bicarbonate solution.
The nurse should inform the client that mouth-
washes containing alcohol dry the oral mucosa
and can irritate tissue.
The nurse should instruct the client to brush their
remaining teeth with a soft toothbrush at least
twice each day to reduce the risk for gum abra-
sions.
The nurse should avoid using lemon-glycerin
sponges because they can cause erosion of the
client's tooth enamel, dry the mucous membranes,
and increase the client's current discomfort.
3. A nurse is planning care Speech-language pathologist
for a client who has dys-
phagia and is at risk The nurse should recommend a referral for a client
for aspiration. Which of who has dysphagia to a speech-language pathol-
the following referrals ogist. Clients who have dysphagia have difficul-
should the nurse make? ty swallowing and are at risk for aspiration. The
speech-language pathologist can perform a swal-
low study to determine the extent of the client's
dysphagia and work with the client to develop new
swallowing techniques.
4. A nurse is planning - Establish the client's learning needs
teaching for a client who
has a new diagnosis of - Determine the client's literacy level
type 2 diabetes mellitus.
Which of the following - Evaluate the client's readiness for learning
actions should the nurse
take prior to performing - Identify the client's learning style
the teaching? (select all
that apply)
5. A nurse is preparing to Previous treatments
notify the provider about
a change in a client's sta- The nurse should include previous treatments in
, RN VATI Fundamentals Assessment
tus. Which of the follow- the "background" portion of the SBAR commu-
ing information should nication tool. Other information the nurse should
the nurse plan to include include in the "background" portion is the client's
in the "background" por- admission history, diagnosis, pertinent medical
tion of the SBAR com- history, and code status. The nurse should include
munication tool? physical findings in the "assessment" portion of
the SBAR communication tool. The nurse should
include questions regarding client care in the "rec-
ommendation" portion of the SBAR communica-
tion tool. The nurse should include the client's
present condition in the "situation" portion of the
SBAR communication tool.
6. A nurse is providing dis- "I will store oxygen tanks in an upright position"
charge teaching to a
client who has a new This statement by the client indicates an under-
prescription for home standing of the teaching. The nurse should in-
oxygen therapy utiliz- struct the client to store oxygen tanks in an up-
ing a compressed oxy- right position in a holder to prevent damage to
gen system. Which of the tank and injury to the client and the client's
the following statements family. The nurse should instruct the client to check
by the client indicates the oxygen equipment at least once daily to de-
an understanding of the termine if it is set to the prescribed oxygen rate.
teaching? The nurse should instruct the client to place the
oxygen equipment 2.4 m (8 ft) from a heat source
to prevent injury from accidental combustion.
7. A nurse is caring for "It must me a very difficult time for you."
a client who has termi-
nal cancer. The client be- The nurse is using the therapeutic communication
gins to cry and says, technique of verbalizing the implied. This tech-
"I am afraid of dying." nique puts into words what the client has said
Which of the following indirectly and creates a more positive nurse-client
responses should the relationship.
nurse make?
8. A nurse is assessing Fear of medical test results
a client's coping skills.
Which of the following Fear of medical test results is an internal stressor
1. A nurse is preparing 1: Draw up the volume of insulin from the interme-
to mix short-acting and diate-acting insulin vial.
intermediate-acting in-
sulin in one syringe to 2: Inject the volume of air equal to the amount
administer to a client of insulin to withdraw from the intermediate-acting
who has type 1 diabetes insulin vial.
mellitus. Identify the se-
quence the nurse should 3: Inject the volume of air equal to the insulin dose
follow. form the short-acting insulin vial
4: Withdraw the prescribed amount of insulin form
the short-acting insulin vial.
5: Withdraw the prescribed amount of insulin form
the intermediate-acting insulin vial.
To mix insulin from two vials in the same syringe,
the nurse should first draw up a volume of air
equal to the volume of insulin from the intermedi-
ate-acting insulin vial. The nurse should then inject
the volume of air equal to the amount of insulin
to withdraw from the intermediate-acting insulin
vial, making sure the needle does not touch the
insulin. Next, the nurse should inject the volume of
air equal to the insulin dose from the short-acting
insulin vial. Then, the nurse should withdraw the
prescribed amount of insulin from the short-acting
insulin vial. Lastly, the nurse should withdraw the
prescribed amount of insulin from the intermedi-
ate-acting insulin vial. The insulins are now mixed
and ready to administer.
2. A nurse is assessing a Advise the client to rinse their mouth and dentures
client who wears par- after each meal.
tial dentures and reports
mouth pain. Which of the The nurse should advise the client to rinse their
following actions should mouth and dentures after each meal to remove
the nurse take? food and particles and to promote healing of gums
and oral mucosa.
,RN VATI Fundamentals Assessment
The nurse should instruct the client to rinse their
mouth four times each day with mild rinses, such
as normal saline or sodium bicarbonate solution.
The nurse should inform the client that mouth-
washes containing alcohol dry the oral mucosa
and can irritate tissue.
The nurse should instruct the client to brush their
remaining teeth with a soft toothbrush at least
twice each day to reduce the risk for gum abra-
sions.
The nurse should avoid using lemon-glycerin
sponges because they can cause erosion of the
client's tooth enamel, dry the mucous membranes,
and increase the client's current discomfort.
3. A nurse is planning care Speech-language pathologist
for a client who has dys-
phagia and is at risk The nurse should recommend a referral for a client
for aspiration. Which of who has dysphagia to a speech-language pathol-
the following referrals ogist. Clients who have dysphagia have difficul-
should the nurse make? ty swallowing and are at risk for aspiration. The
speech-language pathologist can perform a swal-
low study to determine the extent of the client's
dysphagia and work with the client to develop new
swallowing techniques.
4. A nurse is planning - Establish the client's learning needs
teaching for a client who
has a new diagnosis of - Determine the client's literacy level
type 2 diabetes mellitus.
Which of the following - Evaluate the client's readiness for learning
actions should the nurse
take prior to performing - Identify the client's learning style
the teaching? (select all
that apply)
5. A nurse is preparing to Previous treatments
notify the provider about
a change in a client's sta- The nurse should include previous treatments in
, RN VATI Fundamentals Assessment
tus. Which of the follow- the "background" portion of the SBAR commu-
ing information should nication tool. Other information the nurse should
the nurse plan to include include in the "background" portion is the client's
in the "background" por- admission history, diagnosis, pertinent medical
tion of the SBAR com- history, and code status. The nurse should include
munication tool? physical findings in the "assessment" portion of
the SBAR communication tool. The nurse should
include questions regarding client care in the "rec-
ommendation" portion of the SBAR communica-
tion tool. The nurse should include the client's
present condition in the "situation" portion of the
SBAR communication tool.
6. A nurse is providing dis- "I will store oxygen tanks in an upright position"
charge teaching to a
client who has a new This statement by the client indicates an under-
prescription for home standing of the teaching. The nurse should in-
oxygen therapy utiliz- struct the client to store oxygen tanks in an up-
ing a compressed oxy- right position in a holder to prevent damage to
gen system. Which of the tank and injury to the client and the client's
the following statements family. The nurse should instruct the client to check
by the client indicates the oxygen equipment at least once daily to de-
an understanding of the termine if it is set to the prescribed oxygen rate.
teaching? The nurse should instruct the client to place the
oxygen equipment 2.4 m (8 ft) from a heat source
to prevent injury from accidental combustion.
7. A nurse is caring for "It must me a very difficult time for you."
a client who has termi-
nal cancer. The client be- The nurse is using the therapeutic communication
gins to cry and says, technique of verbalizing the implied. This tech-
"I am afraid of dying." nique puts into words what the client has said
Which of the following indirectly and creates a more positive nurse-client
responses should the relationship.
nurse make?
8. A nurse is assessing Fear of medical test results
a client's coping skills.
Which of the following Fear of medical test results is an internal stressor
