VATI RN Comprehensive Predictor Form A|
180 Questions and Correct Answers and
Explanations for Guaranteed Pass
A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery
suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of
the following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam
Correct Answer: C. Prepare the client for a cesarean section
Rationale: Complete placenta previa involves the placenta covering the cervical os, posing a
significant risk of hemorrhage during vaginal delivery. A cesarean section is the safest delivery
method to prevent complications for both the mother and fetus. Rupturing the amniotic sac or
performing a vaginal exam could exacerbate bleeding, and pain medication is not the priority in
this situation.
A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which
of the following statements should the nurse document in an incident report?
A. Client fell out of bed because an assistive personnel left the rails of the bed down
B. Client’s roommate thinks the client is confused and fell when getting out of bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table
Correct Answer: D. Client found lying on the floor near the bedside table
Rationale: Incident reports should be factual and objective, avoiding assumptions or blame.
Option D provides a clear, objective description of the situation without speculating on the cause,
unlike the other options, which include assumptions or subjective interpretations.
,A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit.
Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect
tomorrow
D. A 14-year-old client who is scheduled for discharge today following placement of a
Herrington rod
Correct Answer: A. A 10-year-old client who has pneumonia and is receiving respiratory
treatments
Rationale: A float nurse from a medical unit is likely familiar with administering respiratory
treatments, which are less specialized than caring for clients with cancer, surgical needs, or
complex discharge planning. The other clients require more specialized knowledge or
preparation, which may be outside the float nurse’s expertise.
A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse
should plan to monitor for which of the following adverse reactions?
A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension
Correct Answer: B. Ototoxicity
Rationale: Vancomycin is known to cause ototoxicity (hearing loss or tinnitus) and
nephrotoxicity. Monitoring for hearing changes or renal function is essential. The other options
are not commonly associated with vancomycin’s adverse effects.
A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
,Correct Answer: A. Generalized edema
Rationale: Water intoxication causes hyponatremia, leading to fluid shifts and generalized
edema due to water retention in tissues. Elevated urine specific gravity, increased hematocrit,
and thready pulse are not typical findings; instead, urine specific gravity is usually low, and
hematocrit may be diluted.
A home health nurse is conducting an initial home visit for a client who has terminal breast
cancer. The client has two school-age children and a limited support system. Which of the
following is the priority nursing action?
A. Inform the client of available community resources
B. Assist the client in finding childcare options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis
Correct Answer: A. Inform the client of available community resources
Rationale: The priority is to connect the client with resources to support their needs, given their
limited support system and the demands of caring for children while managing a terminal illness.
This action addresses immediate and long-term needs comprehensively.
A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the
following findings should cause the nurse to suspect a skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry
Correct Answer: A. Clear fluid drainage from the nares
Rationale: Clear fluid from the nares may indicate cerebrospinal fluid (CSF) leakage, a hallmark
sign of a skull fracture, which requires urgent evaluation. The other findings are less specific to
skull fractures and more common with nasal fractures or other injuries.
A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks
of gestation and has bacterial vaginosis. The nurse should recognize that which of the following
clinical findings are associated with this infection?
, A. Profuse milky white discharge
B. Frequency and dysuria
C. Low-grade fever
D. Hematuria
Correct Answer: A. Profuse milky white discharge
Rationale: Bacterial vaginosis typically presents with a thin, milky white or gray discharge with
a fishy odor. Frequency, dysuria, fever, and hematuria are more indicative of urinary tract
infections or other conditions, not bacterial vaginosis.
A nurse is discussing the Z-track administration of hydroxyzine with a newly licensed nurse.
Which of the following statements indicates the newly licensed nurse understands the purpose of
the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
Correct Answer: B. This technique decreases the risk of subcutaneous infiltration
Rationale: The Z-track method prevents medication leakage into subcutaneous tissue, reducing
irritation and ensuring proper intramuscular delivery. It does not directly prevent sciatic nerve
injury, increase absorption rates, or allow larger volumes of medication.
A nurse is caring for a full-term newborn immediately following birth. Which of the following
actions should the nurse take first?
A. Instill erythromycin ophthalmic ointment in the newborn’s eyes
B. Weigh the newborn
C. Place identification bracelets on the newborn
D. Dry the newborn
Correct Answer: D. Dry the newborn
Rationale: Drying the newborn is the priority to prevent hypothermia, which can occur rapidly
due to wet skin and exposure. This action supports thermoregulation, a critical immediate need.
Other actions, like administering erythromycin or weighing, follow after stabilizing the newborn.
180 Questions and Correct Answers and
Explanations for Guaranteed Pass
A client who has a diagnosis of complete placenta previa is admitted to the labor and delivery
suite at 36 weeks gestation with contractions 5 min in frequency and 1 min in duration. Which of
the following actions should the nurse take?
A. Rupture the amniotic sac
B. Medicate the client for pain
C. Prepare the client for a cesarean section
D. Perform a vaginal exam
Correct Answer: C. Prepare the client for a cesarean section
Rationale: Complete placenta previa involves the placenta covering the cervical os, posing a
significant risk of hemorrhage during vaginal delivery. A cesarean section is the safest delivery
method to prevent complications for both the mother and fetus. Rupturing the amniotic sac or
performing a vaginal exam could exacerbate bleeding, and pain medication is not the priority in
this situation.
A nurse enters a client's room and finds the client lying on the floor in a puddle of water. Which
of the following statements should the nurse document in an incident report?
A. Client fell out of bed because an assistive personnel left the rails of the bed down
B. Client’s roommate thinks the client is confused and fell when getting out of bed
C. Client appears to have slipped in water but reports no injuries
D. Client found lying on the floor near the bedside table
Correct Answer: D. Client found lying on the floor near the bedside table
Rationale: Incident reports should be factual and objective, avoiding assumptions or blame.
Option D provides a clear, objective description of the situation without speculating on the cause,
unlike the other options, which include assumptions or subjective interpretations.
,A charge nurse on a pediatric unit is making assignments for a float nurse from the medical unit.
Which of the following clients is appropriate to assign to the float nurse?
A. A 10-year-old client who has pneumonia and is receiving respiratory treatments
B. A 4-year-old client who has a Wilms tumor and is receiving chemotherapy
C. An 8-month-old client who is scheduled for a surgical repair of a ventricular septal defect
tomorrow
D. A 14-year-old client who is scheduled for discharge today following placement of a
Herrington rod
Correct Answer: A. A 10-year-old client who has pneumonia and is receiving respiratory
treatments
Rationale: A float nurse from a medical unit is likely familiar with administering respiratory
treatments, which are less specialized than caring for clients with cancer, surgical needs, or
complex discharge planning. The other clients require more specialized knowledge or
preparation, which may be outside the float nurse’s expertise.
A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse
should plan to monitor for which of the following adverse reactions?
A. Hepatotoxicity
B. Ototoxicity
C. Hypercalcemia
D. Hypertension
Correct Answer: B. Ototoxicity
Rationale: Vancomycin is known to cause ototoxicity (hearing loss or tinnitus) and
nephrotoxicity. Monitoring for hearing changes or renal function is essential. The other options
are not commonly associated with vancomycin’s adverse effects.
A nurse is assessing an infant who has water intoxication. Which of the following findings
should the nurse expect?
A. Generalized edema
B. Elevated urine specific gravity
C. Thready pulse
D. Increased hematocrit
,Correct Answer: A. Generalized edema
Rationale: Water intoxication causes hyponatremia, leading to fluid shifts and generalized
edema due to water retention in tissues. Elevated urine specific gravity, increased hematocrit,
and thready pulse are not typical findings; instead, urine specific gravity is usually low, and
hematocrit may be diluted.
A home health nurse is conducting an initial home visit for a client who has terminal breast
cancer. The client has two school-age children and a limited support system. Which of the
following is the priority nursing action?
A. Inform the client of available community resources
B. Assist the client in finding childcare options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis
Correct Answer: A. Inform the client of available community resources
Rationale: The priority is to connect the client with resources to support their needs, given their
limited support system and the demands of caring for children while managing a terminal illness.
This action addresses immediate and long-term needs comprehensively.
A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the
following findings should cause the nurse to suspect a skull fracture?
A. Clear fluid drainage from the nares
B. Report of pain around the eyes
C. Dried blood in the mouth
D. Mandibular asymmetry
Correct Answer: A. Clear fluid drainage from the nares
Rationale: Clear fluid from the nares may indicate cerebrospinal fluid (CSF) leakage, a hallmark
sign of a skull fracture, which requires urgent evaluation. The other findings are less specific to
skull fractures and more common with nasal fractures or other injuries.
A nurse in an urgent care clinic is collecting admission history from a client who is at 16 weeks
of gestation and has bacterial vaginosis. The nurse should recognize that which of the following
clinical findings are associated with this infection?
, A. Profuse milky white discharge
B. Frequency and dysuria
C. Low-grade fever
D. Hematuria
Correct Answer: A. Profuse milky white discharge
Rationale: Bacterial vaginosis typically presents with a thin, milky white or gray discharge with
a fishy odor. Frequency, dysuria, fever, and hematuria are more indicative of urinary tract
infections or other conditions, not bacterial vaginosis.
A nurse is discussing the Z-track administration of hydroxyzine with a newly licensed nurse.
Which of the following statements indicates the newly licensed nurse understands the purpose of
the technique?
A. This technique prevents injury to the sciatic nerve
B. This technique decreases the risk of subcutaneous infiltration
C. This technique allows a larger amount of medication to be injected
D. This technique increases the absorption rate of the drug
Correct Answer: B. This technique decreases the risk of subcutaneous infiltration
Rationale: The Z-track method prevents medication leakage into subcutaneous tissue, reducing
irritation and ensuring proper intramuscular delivery. It does not directly prevent sciatic nerve
injury, increase absorption rates, or allow larger volumes of medication.
A nurse is caring for a full-term newborn immediately following birth. Which of the following
actions should the nurse take first?
A. Instill erythromycin ophthalmic ointment in the newborn’s eyes
B. Weigh the newborn
C. Place identification bracelets on the newborn
D. Dry the newborn
Correct Answer: D. Dry the newborn
Rationale: Drying the newborn is the priority to prevent hypothermia, which can occur rapidly
due to wet skin and exposure. This action supports thermoregulation, a critical immediate need.
Other actions, like administering erythromycin or weighing, follow after stabilizing the newborn.
