VATI COMPREHENSIVE GREEN
LIGHT RETAKE ACTUAL EXAM
QUESTIONS AND CORRECT
DETAILED ANSWERS
### Q1. A nurse is performing triage following a natural
disaster. Which client should the nurse identify as the highest
priority to receive care?
A) A client who has agonal respirations
,B) A client who has an open skull fracture and is unresponsive
C) A client who has a traumatic arm amputation
D) A client who has a fracture of the femur
**Answer:** C) Traumatic arm amputation
**Rationale:** In disaster triage, clients with life-threatening
but potentially salvageable injuries are assigned the highest
priority (RED tag). A traumatic amputation with active
hemorrhage requires immediate life-saving intervention .
### Q2. A nurse on a medical unit has just received change-of-
shift report. Which client should the nurse assess first?
A) A 68-year-old client who had a myocardial infarction 2 days
ago and reports chest pain 4/10
B) A 48-year-old client with AIDS, PCP, and temperature 38.3°C
(101°F)
C) A 60-year-old client with COPD on 2 L/min O₂ with SpO₂ 89%
D) A 26-year-old female with PID unable to void
,**Answer:** A) 68-year-old with chest pain post-MI
**Rationale:** Chest pain in a post-MI patient may indicate
reinfarction or complication (e.g., ventricular aneurysm,
pericarditis). This requires immediate assessment using the ABC
framework. COPD with SpO₂ 89% on oxygen is second priority .
### Q3. At the start of an evening shift on a cardiac unit, an LPN
brings a list of client reports. Which report should the nurse
assess first?
A) Constipation
B) Indigestion
C) Swollen ankles
D) Urinary frequency
**Answer:** B) Indigestion
**Rationale:** Indigestion can be an atypical presentation of
myocardial ischemia, especially in women, older adults, and
diabetics. This symptom requires immediate cardiac
assessment before other, more stable symptoms .
, ### Q4. A nurse manager is reviewing documentation
standards with new nurses. Which statement should be
included?
A) Include the complete name of the medication morphine
sulfate
B) Do not use a leading zero prior to a decimal point
C) Write the letter U when noting the dosage of insulin
D) Use the abbreviation QOD when indicating every other day
**Answer:** A) Include the complete name of the medication
morphine sulfate
**Rationale:** Unsafe abbreviations include "MS" (could mean
morphine sulfate OR magnesium sulfate). Complete medication
names should be written to prevent medication errors. "U" can
be mistaken for "0"; "QOD" is often misinterpreted .
### Q5. A charge nurse on a pediatric unit is making
assignments for a float nurse from the medical unit. Which
client is appropriate to assign to the float nurse?
LIGHT RETAKE ACTUAL EXAM
QUESTIONS AND CORRECT
DETAILED ANSWERS
### Q1. A nurse is performing triage following a natural
disaster. Which client should the nurse identify as the highest
priority to receive care?
A) A client who has agonal respirations
,B) A client who has an open skull fracture and is unresponsive
C) A client who has a traumatic arm amputation
D) A client who has a fracture of the femur
**Answer:** C) Traumatic arm amputation
**Rationale:** In disaster triage, clients with life-threatening
but potentially salvageable injuries are assigned the highest
priority (RED tag). A traumatic amputation with active
hemorrhage requires immediate life-saving intervention .
### Q2. A nurse on a medical unit has just received change-of-
shift report. Which client should the nurse assess first?
A) A 68-year-old client who had a myocardial infarction 2 days
ago and reports chest pain 4/10
B) A 48-year-old client with AIDS, PCP, and temperature 38.3°C
(101°F)
C) A 60-year-old client with COPD on 2 L/min O₂ with SpO₂ 89%
D) A 26-year-old female with PID unable to void
,**Answer:** A) 68-year-old with chest pain post-MI
**Rationale:** Chest pain in a post-MI patient may indicate
reinfarction or complication (e.g., ventricular aneurysm,
pericarditis). This requires immediate assessment using the ABC
framework. COPD with SpO₂ 89% on oxygen is second priority .
### Q3. At the start of an evening shift on a cardiac unit, an LPN
brings a list of client reports. Which report should the nurse
assess first?
A) Constipation
B) Indigestion
C) Swollen ankles
D) Urinary frequency
**Answer:** B) Indigestion
**Rationale:** Indigestion can be an atypical presentation of
myocardial ischemia, especially in women, older adults, and
diabetics. This symptom requires immediate cardiac
assessment before other, more stable symptoms .
, ### Q4. A nurse manager is reviewing documentation
standards with new nurses. Which statement should be
included?
A) Include the complete name of the medication morphine
sulfate
B) Do not use a leading zero prior to a decimal point
C) Write the letter U when noting the dosage of insulin
D) Use the abbreviation QOD when indicating every other day
**Answer:** A) Include the complete name of the medication
morphine sulfate
**Rationale:** Unsafe abbreviations include "MS" (could mean
morphine sulfate OR magnesium sulfate). Complete medication
names should be written to prevent medication errors. "U" can
be mistaken for "0"; "QOD" is often misinterpreted .
### Q5. A charge nurse on a pediatric unit is making
assignments for a float nurse from the medical unit. Which
client is appropriate to assign to the float nurse?
