①
VATI RN GREENLIGHT PRACTICE
QUESTIONS AND VERIFIED CORRECT
DETAILED ANSWERS WITH RATIONALES
PLUS A CHEAT SHEET.
, ②
---section A. Management of care
**1. A nurse is planning care for a group of clients. Which of the
following clients should the nurse see first?**
* A. A client who had an abdominal surgery 4 hours ago and reports a
pain level of 7 on a scale of 0 to 10.
* B. A client with a history of heart failure who has developed a new
onset of shortness of breath and restlessness.
* C. A client receiving a continuous IV infusion who reports that the
pump is alarming "occlusion."
* D. A client with diabetes mellitus whose morning blood glucose was
150 mg/dL.
**Correct Answer: B**
**Rationale:** New onset respiratory distress and restlessness are
early signs of pulmonary edema or worsening heart failure, requiring
immediate assessment (ABC framework).
**2. A charge nurse is delegating tasks to an assistive personnel (AP).
Which of the following tasks is appropriate for the AP?**
* A. Obtaining a clean-catch urine specimen from a client.
* B. Adjusting the flow rate of an oxygen nasal cannula.
* C. Evaluating the effectiveness of a client's pain medication.
* D. Showing a client how to use an incentive spirometer.
, ③
**Correct Answer: A**
**Rationale:** Collection of non-invasive specimens is a routine task
within the scope of an AP. Remember E.A.T: Nurses do not delegate
Evaluation, Assessment, or Teaching.
**3. A nurse is caring for four clients. Which client should the nurse
assess first using the safety and risk reduction framework?**
* A. A client who is confused and attempting to pull out their peripheral
IV line.
* B. A client with a cast on the right leg who reports new onset of
tingling and "pins and needles" in the toes.
* C. A client who is 1 day postoperative and has not voided in 6 hours.
* D. A client with a pressure injury who requires a dressing change.
**Correct Answer: B**
**Rationale:** Paresthesia is an early sign of compartment syndrome, a
surgical emergency that requires immediate intervention to prevent
limb loss.
**4. A nurse is preparing to witness a client sign an informed consent
form for a procedure. What is the nurse's primary responsibility in this
role?**
* A. Explaining the risks and benefits of the procedure to the client.
* B. Ensuring the client understands the alternatives to the procedure.
* C. Verifying that the client is signing the form voluntarily and is
competent.
, ④
* D. Confirming that the client's family agrees with the decision.
**Correct Answer: C**
**Rationale:** The nurse's role as a witness is limited to verifying that
the signature is authentic and the client appears competent and
voluntary.
**5. A nurse is caring for a client who is in terminal stages of cancer.
The client’s family asks the nurse not to tell the client about the poor
prognosis. Which ethical principle should the nurse prioritize?**
* A. Fidelity
* B. Autonomy
* C. Justice
* D. Nonmaleficence
**Correct Answer: B**
**Rationale:** Autonomy involves the client's right to make their own
decisions and be informed about their own health status.
**6. A nurse receives a change-of-shift report. Which client should the
nurse assess first?**
* A. A client who has a chest tube and 100 mL of red drainage in the
last hour.
* B. A client with pneumonia who has an oxygen saturation of 92% on
room air.
* C. A client with a total hip arthroplasty who is requesting assistance
to the bedside commode.
VATI RN GREENLIGHT PRACTICE
QUESTIONS AND VERIFIED CORRECT
DETAILED ANSWERS WITH RATIONALES
PLUS A CHEAT SHEET.
, ②
---section A. Management of care
**1. A nurse is planning care for a group of clients. Which of the
following clients should the nurse see first?**
* A. A client who had an abdominal surgery 4 hours ago and reports a
pain level of 7 on a scale of 0 to 10.
* B. A client with a history of heart failure who has developed a new
onset of shortness of breath and restlessness.
* C. A client receiving a continuous IV infusion who reports that the
pump is alarming "occlusion."
* D. A client with diabetes mellitus whose morning blood glucose was
150 mg/dL.
**Correct Answer: B**
**Rationale:** New onset respiratory distress and restlessness are
early signs of pulmonary edema or worsening heart failure, requiring
immediate assessment (ABC framework).
**2. A charge nurse is delegating tasks to an assistive personnel (AP).
Which of the following tasks is appropriate for the AP?**
* A. Obtaining a clean-catch urine specimen from a client.
* B. Adjusting the flow rate of an oxygen nasal cannula.
* C. Evaluating the effectiveness of a client's pain medication.
* D. Showing a client how to use an incentive spirometer.
, ③
**Correct Answer: A**
**Rationale:** Collection of non-invasive specimens is a routine task
within the scope of an AP. Remember E.A.T: Nurses do not delegate
Evaluation, Assessment, or Teaching.
**3. A nurse is caring for four clients. Which client should the nurse
assess first using the safety and risk reduction framework?**
* A. A client who is confused and attempting to pull out their peripheral
IV line.
* B. A client with a cast on the right leg who reports new onset of
tingling and "pins and needles" in the toes.
* C. A client who is 1 day postoperative and has not voided in 6 hours.
* D. A client with a pressure injury who requires a dressing change.
**Correct Answer: B**
**Rationale:** Paresthesia is an early sign of compartment syndrome, a
surgical emergency that requires immediate intervention to prevent
limb loss.
**4. A nurse is preparing to witness a client sign an informed consent
form for a procedure. What is the nurse's primary responsibility in this
role?**
* A. Explaining the risks and benefits of the procedure to the client.
* B. Ensuring the client understands the alternatives to the procedure.
* C. Verifying that the client is signing the form voluntarily and is
competent.
, ④
* D. Confirming that the client's family agrees with the decision.
**Correct Answer: C**
**Rationale:** The nurse's role as a witness is limited to verifying that
the signature is authentic and the client appears competent and
voluntary.
**5. A nurse is caring for a client who is in terminal stages of cancer.
The client’s family asks the nurse not to tell the client about the poor
prognosis. Which ethical principle should the nurse prioritize?**
* A. Fidelity
* B. Autonomy
* C. Justice
* D. Nonmaleficence
**Correct Answer: B**
**Rationale:** Autonomy involves the client's right to make their own
decisions and be informed about their own health status.
**6. A nurse receives a change-of-shift report. Which client should the
nurse assess first?**
* A. A client who has a chest tube and 100 mL of red drainage in the
last hour.
* B. A client with pneumonia who has an oxygen saturation of 92% on
room air.
* C. A client with a total hip arthroplasty who is requesting assistance
to the bedside commode.
