PN VATI FUNDAMENTALS
1. A nurse is collecting data from a client Thirst.
who has an elevated temperature with no
sweating. Which of the following findings Rationale:
is an indication of hypernatremia? Thirst, combined with an elevated temperature
and a lack of sweating, can be an indication of
–Thirst hypernatremia.
–Muscle twitching
–Headache
–Abdominal cramps
2. A nurse is caring for a client who reports Close the door to the client's room.
difficulty sleeping due to the noise on
the nursing unit. Which of the following Rationale:
actions should the nurse take to reduce The nurse should close the door to the client's
environmental noise? room whenever possible to reduce environ-
mental noise.
–Close the door to the client's room.
–Turn off the alarms and beeps on moni-
toring equipment.
–Conduct change-of-shift report outside
the client's door.
–Keep the television on low in the client's
room.
3. A nurse is reinforcing teaching about Identify areas of concern.
health promotion with a client. Which of
the following actions should the nurse Rationale:
take first to promote effective learning? The first action the nurse should take when us-
ing the nursing process is to collect data from
–Identify areas of concern. the client. Identifying and understanding the
–Prioritize learning objectives. client's concerns prior to reinforcing teaching
promotes effective learning.
, PN VATI FUNDAMENTALS
–Demonstrate psychomotor skills.
–Observe nonverbal communication.
4. A home health nurse is assisting with the Clarify the role of this individual nurse.
plan of care for a client. Which of the
following should the nurse include dur- Rationale:
ing the orientation phase of the helping The nurse should plan to establish a warm,
relationship? caring relationship while clarifying the role of
each participant, which occurs during the ori-
–Review current client data. entation phase of the relationship.
–Assist to meet client goals.
–Review shared memories of interactions
with client.
–Clarify the role of this individual nurse.
5. A nurse is preparing to assist with the The wheel locks on the bed are malfunction-
admission of a client who has pneumo- ing.
nia. Which of the following observations
about the client's room requires immedi- Rationale:
ate attention? The greatest risk to this client is injury from a
fall when getting into or out of a bed that is
–The wall BP gauge is missing. unstable due to malfunctioning locks. There-
–The room has no IV infusion pump. fore, the priority is to report and replace the
–The examination light above the bed bed before admitting the client to the room.
does not work.
–The wheel locks on the bed are malfunc-
tioning.
6. A nurse is reinforcing teaching about Participate in screenings for tuberculosis.
health promotion with an older adult
client. Which of the following instructions Rationale:
to the client is an example of secondary The nurse should encourage the client to par-
prevention? ticipate in screenings for tuberculosis, a sec-
, PN VATI FUNDAMENTALS
ondary prevention measure. Secondary pre-
–Participate in screenings for tuberculo- vention measures focus on diagnosis and early
sis. intervention.
–Follow dietary recommendations to re-
duce the risk for osteoporosis.
–Limit alcohol intake to one drink per day.
–Perform yoga exercises three times per
week.
7. A licensed practical nurse (LPN) is receiv- Staging a pressure ulcer.
ing change-of-shift report for a client who
had a stroke. For which of the follow- Rationale:
ing tasks should the nurse request assis- An LPN can collect data for the client and report
tance from a registered nurse (RN)? findings to an RN. However, staging a pressure
ulcer requires advance knowledge and skill,
–Administering a cleansing enema and is outside the scope of practice of an LPN.
–Staging a pressure ulcer An RN should assess the stage of a complex
–Inserting an indwelling urinary catheter wound, such as a pressure ulcer, and provide
–Performing passive range-of-motion ex- primary client teaching about pressure ulcer
ercises prevention and care.
8. A nurse is reinforcing teaching about "I will secure all of my electrical cords to the
home safety with a client who is at risk for baseboard."
falls. Which of the following client state-
ments indicates an understanding of the Rationale:
teaching? Securing cords along the baseboards with
electrical tape minimizes the tripping hazard
–"I will keep my floors well waxed." for clients who are at risk for falls.
–"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."
1. A nurse is collecting data from a client Thirst.
who has an elevated temperature with no
sweating. Which of the following findings Rationale:
is an indication of hypernatremia? Thirst, combined with an elevated temperature
and a lack of sweating, can be an indication of
–Thirst hypernatremia.
–Muscle twitching
–Headache
–Abdominal cramps
2. A nurse is caring for a client who reports Close the door to the client's room.
difficulty sleeping due to the noise on
the nursing unit. Which of the following Rationale:
actions should the nurse take to reduce The nurse should close the door to the client's
environmental noise? room whenever possible to reduce environ-
mental noise.
–Close the door to the client's room.
–Turn off the alarms and beeps on moni-
toring equipment.
–Conduct change-of-shift report outside
the client's door.
–Keep the television on low in the client's
room.
3. A nurse is reinforcing teaching about Identify areas of concern.
health promotion with a client. Which of
the following actions should the nurse Rationale:
take first to promote effective learning? The first action the nurse should take when us-
ing the nursing process is to collect data from
–Identify areas of concern. the client. Identifying and understanding the
–Prioritize learning objectives. client's concerns prior to reinforcing teaching
promotes effective learning.
, PN VATI FUNDAMENTALS
–Demonstrate psychomotor skills.
–Observe nonverbal communication.
4. A home health nurse is assisting with the Clarify the role of this individual nurse.
plan of care for a client. Which of the
following should the nurse include dur- Rationale:
ing the orientation phase of the helping The nurse should plan to establish a warm,
relationship? caring relationship while clarifying the role of
each participant, which occurs during the ori-
–Review current client data. entation phase of the relationship.
–Assist to meet client goals.
–Review shared memories of interactions
with client.
–Clarify the role of this individual nurse.
5. A nurse is preparing to assist with the The wheel locks on the bed are malfunction-
admission of a client who has pneumo- ing.
nia. Which of the following observations
about the client's room requires immedi- Rationale:
ate attention? The greatest risk to this client is injury from a
fall when getting into or out of a bed that is
–The wall BP gauge is missing. unstable due to malfunctioning locks. There-
–The room has no IV infusion pump. fore, the priority is to report and replace the
–The examination light above the bed bed before admitting the client to the room.
does not work.
–The wheel locks on the bed are malfunc-
tioning.
6. A nurse is reinforcing teaching about Participate in screenings for tuberculosis.
health promotion with an older adult
client. Which of the following instructions Rationale:
to the client is an example of secondary The nurse should encourage the client to par-
prevention? ticipate in screenings for tuberculosis, a sec-
, PN VATI FUNDAMENTALS
ondary prevention measure. Secondary pre-
–Participate in screenings for tuberculo- vention measures focus on diagnosis and early
sis. intervention.
–Follow dietary recommendations to re-
duce the risk for osteoporosis.
–Limit alcohol intake to one drink per day.
–Perform yoga exercises three times per
week.
7. A licensed practical nurse (LPN) is receiv- Staging a pressure ulcer.
ing change-of-shift report for a client who
had a stroke. For which of the follow- Rationale:
ing tasks should the nurse request assis- An LPN can collect data for the client and report
tance from a registered nurse (RN)? findings to an RN. However, staging a pressure
ulcer requires advance knowledge and skill,
–Administering a cleansing enema and is outside the scope of practice of an LPN.
–Staging a pressure ulcer An RN should assess the stage of a complex
–Inserting an indwelling urinary catheter wound, such as a pressure ulcer, and provide
–Performing passive range-of-motion ex- primary client teaching about pressure ulcer
ercises prevention and care.
8. A nurse is reinforcing teaching about "I will secure all of my electrical cords to the
home safety with a client who is at risk for baseboard."
falls. Which of the following client state-
ments indicates an understanding of the Rationale:
teaching? Securing cords along the baseboards with
electrical tape minimizes the tripping hazard
–"I will keep my floors well waxed." for clients who are at risk for falls.
–"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."
