VATI Green Light
Comprehensive Exam –
Form A, B, C | Questions
and Verified Answers
1. A nurse is assessing a client who has heart failure and is receiving
furosemide. Which finding indicates the medication is effective?
A. Decreased crackles in lung bases
B. Increased jugular venous distension
C. Weight gain of 1 kg in 24 hours
D. Blood pressure 158/90 mm Hg
Answer: A. Furosemide is a loop diuretic that reduces fluid overload.
Decreased crackles indicate reduced pulmonary congestion, a therapeutic
effect.
2. A nurse is teaching a client with type 2 diabetes about self-monitoring of
blood glucose. Which statement by the client indicates understanding?
A. "I should wash my hands with soap and water before testing."
B. "I will test my blood glucose immediately after a large meal."
C. "Using alcohol to clean my finger will increase accuracy."
D. "I only need to test once per day because I take oral medication."
Answer: A. Handwashing removes food residue that could alter readings.
Alcohol can dry skin and affect accuracy; testing is best done before meals.
,3. A nurse is caring for a client in the emergency department who reports
chest pain radiating to the left arm. Which priority action should the nurse
take?
A. Obtain a 12-lead ECG
B. Administer sublingual nitroglycerin
C. Ask about risk factors for coronary artery disease
D. Prepare the client for cardiac catheterization
Answer: A. The priority is obtaining an ECG within 10 minutes of arrival to
determine if the pain is due to ST-segment elevation MI (STEMI). Pain relief
and further interventions follow after assessment.
4. A nurse is providing discharge teaching to a client who had a total hip
arthroplasty. Which instruction should the nurse include?
A. "Cross your legs at the ankles when sitting."
B. "Use a raised toilet seat and avoid low chairs."
C. "Sleep on the operative side to promote drainage."
D. "Bend forward at the waist to pick up objects."
Answer: B. A raised toilet seat helps maintain hip flexion <90°, preventing
dislocation. Crossing legs, bending >90°, and sleeping on the operative side
increase dislocation risk.
5. A nurse is reviewing a client’s laboratory results. The client has a
potassium level of 6.2 mEq/L. Which finding should the nurse expect?
A. Flattened T waves
B. Widened QRS complex
C. ST segment elevation
D. Prominent U waves
Answer: B. Hyperkalemia (K+ >5.0) causes peaked T waves, widened QRS,
and eventually asystole. Flattened T waves and U waves are seen in
hypokalemia.
6. A nurse is caring for a client with major depressive disorder who started
taking a selective serotonin reuptake inhibitor (SSRI) 3 days ago. The client
,says, "I don't think this medicine is helping." Which response is most
appropriate?
A. "Let's ask your provider to increase the dose."
B. "It usually takes 4 to 6 weeks to feel the full effect."
C. "You may need to try a different class of antidepressant."
D. "Most people feel better after the first week."
Answer: B. SSRIs have a delayed onset of 4–6 weeks. Setting realistic
expectations improves adherence.
7. A nurse is performing a fall risk assessment on an older adult client.
Which finding places the client at highest risk for falls?
A. Uses a cane for ambulation
B. Takes antihypertensive medication
C. Reports occasional urinary incontinence
D. Has a history of one fall in the past year
Answer: B. Antihypertensives can cause orthostatic hypotension, leading to
sudden falls. While other factors contribute, medication-induced
hypotension is a major modifiable risk.
8. A nurse is preparing to administer a blood transfusion. After priming the
tubing with 0.9% sodium chloride, which action is most important?
A. Verify blood compatibility with another licensed nurse.
B. Ask the client to state their full name and date of birth.
C. Check the client’s vital signs one hour before starting.
D. Warm the blood unit to room temperature before infusion.
Answer: A. Two licensed nurses must verify the blood product, client
identification, and compatibility at the bedside. This is a critical safety step
to prevent hemolytic reactions.
9. A nurse is assessing a 2-day-old newborn. The newborn’s skin appears
yellow, and the bilirubin level is 12 mg/dL. Which action should the nurse
anticipate?
A. Initiate phototherapy
, B. Prepare for exchange transfusion
C. Encourage more frequent breastfeeding
D. Obtain an order for intravenous immunoglobulin
Answer: C. Physiologic jaundice in a term newborn with bilirubin <15
mg/dL in the first 48 hours can often be managed with increased feeding to
promote excretion via stool. Phototherapy is typically started at higher
levels.
10. A nurse is delegating tasks to an assistive personnel (AP). Which task is
appropriate for the AP to perform?
A. Ambulate a client who has a new above-knee amputation.
B. Measure the blood pressure of a client with a chest tube.
C. Feed a client who has dysphagia and thickened liquids.
D. Assist a client with a urinary catheter to ambulate to the bathroom.
Answer: D. APs can assist with ambulation for clients with stable, indwelling
catheters. The other options require nursing judgment or specialized skills.
Questions 11–20
11. A nurse is caring for a client with pneumonia who has a prescription for
oxygen at 2 L/min via nasal cannula. The client’s oxygen saturation is 91%.
Which action should the nurse take first?
A. Increase oxygen to 3 L/min.
B. Encourage deep breathing and coughing.
C. Place the client in a high-Fowler’s position.
D. Notify the respiratory therapist.
Answer: C. High-Fowler’s position improves lung expansion and
oxygenation. This is a simple, immediate intervention before adjusting
oxygen or notifying others.
Comprehensive Exam –
Form A, B, C | Questions
and Verified Answers
1. A nurse is assessing a client who has heart failure and is receiving
furosemide. Which finding indicates the medication is effective?
A. Decreased crackles in lung bases
B. Increased jugular venous distension
C. Weight gain of 1 kg in 24 hours
D. Blood pressure 158/90 mm Hg
Answer: A. Furosemide is a loop diuretic that reduces fluid overload.
Decreased crackles indicate reduced pulmonary congestion, a therapeutic
effect.
2. A nurse is teaching a client with type 2 diabetes about self-monitoring of
blood glucose. Which statement by the client indicates understanding?
A. "I should wash my hands with soap and water before testing."
B. "I will test my blood glucose immediately after a large meal."
C. "Using alcohol to clean my finger will increase accuracy."
D. "I only need to test once per day because I take oral medication."
Answer: A. Handwashing removes food residue that could alter readings.
Alcohol can dry skin and affect accuracy; testing is best done before meals.
,3. A nurse is caring for a client in the emergency department who reports
chest pain radiating to the left arm. Which priority action should the nurse
take?
A. Obtain a 12-lead ECG
B. Administer sublingual nitroglycerin
C. Ask about risk factors for coronary artery disease
D. Prepare the client for cardiac catheterization
Answer: A. The priority is obtaining an ECG within 10 minutes of arrival to
determine if the pain is due to ST-segment elevation MI (STEMI). Pain relief
and further interventions follow after assessment.
4. A nurse is providing discharge teaching to a client who had a total hip
arthroplasty. Which instruction should the nurse include?
A. "Cross your legs at the ankles when sitting."
B. "Use a raised toilet seat and avoid low chairs."
C. "Sleep on the operative side to promote drainage."
D. "Bend forward at the waist to pick up objects."
Answer: B. A raised toilet seat helps maintain hip flexion <90°, preventing
dislocation. Crossing legs, bending >90°, and sleeping on the operative side
increase dislocation risk.
5. A nurse is reviewing a client’s laboratory results. The client has a
potassium level of 6.2 mEq/L. Which finding should the nurse expect?
A. Flattened T waves
B. Widened QRS complex
C. ST segment elevation
D. Prominent U waves
Answer: B. Hyperkalemia (K+ >5.0) causes peaked T waves, widened QRS,
and eventually asystole. Flattened T waves and U waves are seen in
hypokalemia.
6. A nurse is caring for a client with major depressive disorder who started
taking a selective serotonin reuptake inhibitor (SSRI) 3 days ago. The client
,says, "I don't think this medicine is helping." Which response is most
appropriate?
A. "Let's ask your provider to increase the dose."
B. "It usually takes 4 to 6 weeks to feel the full effect."
C. "You may need to try a different class of antidepressant."
D. "Most people feel better after the first week."
Answer: B. SSRIs have a delayed onset of 4–6 weeks. Setting realistic
expectations improves adherence.
7. A nurse is performing a fall risk assessment on an older adult client.
Which finding places the client at highest risk for falls?
A. Uses a cane for ambulation
B. Takes antihypertensive medication
C. Reports occasional urinary incontinence
D. Has a history of one fall in the past year
Answer: B. Antihypertensives can cause orthostatic hypotension, leading to
sudden falls. While other factors contribute, medication-induced
hypotension is a major modifiable risk.
8. A nurse is preparing to administer a blood transfusion. After priming the
tubing with 0.9% sodium chloride, which action is most important?
A. Verify blood compatibility with another licensed nurse.
B. Ask the client to state their full name and date of birth.
C. Check the client’s vital signs one hour before starting.
D. Warm the blood unit to room temperature before infusion.
Answer: A. Two licensed nurses must verify the blood product, client
identification, and compatibility at the bedside. This is a critical safety step
to prevent hemolytic reactions.
9. A nurse is assessing a 2-day-old newborn. The newborn’s skin appears
yellow, and the bilirubin level is 12 mg/dL. Which action should the nurse
anticipate?
A. Initiate phototherapy
, B. Prepare for exchange transfusion
C. Encourage more frequent breastfeeding
D. Obtain an order for intravenous immunoglobulin
Answer: C. Physiologic jaundice in a term newborn with bilirubin <15
mg/dL in the first 48 hours can often be managed with increased feeding to
promote excretion via stool. Phototherapy is typically started at higher
levels.
10. A nurse is delegating tasks to an assistive personnel (AP). Which task is
appropriate for the AP to perform?
A. Ambulate a client who has a new above-knee amputation.
B. Measure the blood pressure of a client with a chest tube.
C. Feed a client who has dysphagia and thickened liquids.
D. Assist a client with a urinary catheter to ambulate to the bathroom.
Answer: D. APs can assist with ambulation for clients with stable, indwelling
catheters. The other options require nursing judgment or specialized skills.
Questions 11–20
11. A nurse is caring for a client with pneumonia who has a prescription for
oxygen at 2 L/min via nasal cannula. The client’s oxygen saturation is 91%.
Which action should the nurse take first?
A. Increase oxygen to 3 L/min.
B. Encourage deep breathing and coughing.
C. Place the client in a high-Fowler’s position.
D. Notify the respiratory therapist.
Answer: C. High-Fowler’s position improves lung expansion and
oxygenation. This is a simple, immediate intervention before adjusting
oxygen or notifying others.
