VATI Comprehensive A (answered)
9. 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 - Prepare the client for a cesarean section
177. 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 - Client found lying on the floor
near the bedside table
178. 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 - A 10-year-old client who has pneumonia and is receiving respiratory
treatments
179. 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 - Ototoxicity
180. 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 - Thready pulse
,1. 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 child care options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis - Inform the client of
available community resources
2. 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 - Clear fluid drainage from the nares
3. 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 - Profuse milky white discharge
4. 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 - This technique decreases
the risk of subcutaneous infiltration
10. 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 - Dry the newborn
11. A nurse is planning to provide community education about viral hepatitis. Which of
the following should the nurse plan to include in the teaching?
A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis
B. Hepatitis B is transmitted by contaminated food
C. Chronic hepatitis can lead to renal cell cancer
,D. Clients who have a history of viral hepatitis are unable to donate blood - Clients who
have a history of viral hepatitis are unable to donate blood
12. A nurse in a residential mental health facility is planning care for a new client who
has obsessive compulsive disorder. Which of the following is appropriate for the nurse
to include in the plan of care?
A. Work with the client to create a flexible daily schedule
B. Gradually decrease the time allowed for ritualistic behavior
C. Offer solutions to assist in problem solving
D. Teach the client to meditate about obsessive thoughts - Work with the client to create
a flexible daily schedule
13. A nurse is assessing an adult male who has a BMI of 20. The nurse should identify
that the client's BMI falls within which of the following categories?
A. Healthy weight
B. Malnutrition
C. Overweight
D. Obesity - Malnutrition
14. A nurse is caring for a client who is nulliparous and in the first stage of labor. The
last internal assessment revealed 100% cervical effacement with 5 cm of dilation. At the
end of the last contraction, the nurse observes a large gush of fluid coming out of the
client's perineal area. Which of the following is a priority action by the nurse?
A. Perform another internal exam
B. Notify the client's provider
C. Check the FHR
D. Obtain a pH test of the fluid - Check the FHR
15. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of
the following interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose meal times - Monitor the client for 1 hr after meals
16. A nurse is performing a skin assessment on a client who has risk factors for
development of skin cancer. The nurse should understand that a suspicious lesion is
A. Asymmetric, with variegated coloring
B. Scaly and red
C. Brown, with a wart-like texture
D. Firm and rubbery - Asymmetric, with variegated coloring
17. A nurse is assessing a client's internal eye structures with an ophthalmoscope.
Which of the following actions should the nurse take?
A. Position the examination light toward the client's face
B. Stand on the right side of the client when examining the left eye
, C. Dim the lights in the room prior to the examination
D. Place the ophthalmoscope directly against the client's forehead - Dim the lights in the
room prior to the examination
18. A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the
following actions should the nurse identify as an indication that the newly licensed nurse
understands wound irrigation?
A. Cleanses the wound with povidone-iodine with cotton balls
B. Administers PO analgesia 20 min prior to irrigation
C. Warms the irrigation solution in the microwave oven prior to application
D. Irrigates the wound from the top to the bottom - Administers PO analgesia 20
minutes prior to irrigation
19. A nurse is planning care for a child who has increased intracranial pressure with a
decrease in level of consciousness. Which of the following interventions should the
nurse include in the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs - Maintain the head at a midline position
20. A nurse notices smoke coming from a client's room and discovers a fire in the
wastebasket. After moving the client to safety, which of the followings is the priority
action?
A. Notify the facility operator
B. Close the fire doors on the unit
C. Turn off oxygen sources
D. Put out the fire with the appropriate extinguisher - Close the fire door on the unit
21. A nurse is talking with an adult child of a client who was involuntarily admitted to an
inpatient mental health facility. Which of the following statements should the nurse
make?
A. The provider will notify your patient's employer about admission to the facility
B. Your parent will have to take the medication that the doctor prescribes
C. Your parent might have electroconvulsive therapy without providing consent
D. The provider can prescribe restraints if your parent tries to harm others - The
provider can prescribe restraints if your parent tries to harm others
22. A nurse is assessing a client who has delirium due to a febrile illness. Which of the
following findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia - Hallucinations
9. 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 - Prepare the client for a cesarean section
177. 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 - Client found lying on the floor
near the bedside table
178. 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 - A 10-year-old client who has pneumonia and is receiving respiratory
treatments
179. 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 - Ototoxicity
180. 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 - Thready pulse
,1. 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 child care options
C. Agree upon short-term goals for the client
D. Ask the client about their understanding of the diagnosis - Inform the client of
available community resources
2. 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 - Clear fluid drainage from the nares
3. 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 - Profuse milky white discharge
4. 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 - This technique decreases
the risk of subcutaneous infiltration
10. 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 - Dry the newborn
11. A nurse is planning to provide community education about viral hepatitis. Which of
the following should the nurse plan to include in the teaching?
A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis
B. Hepatitis B is transmitted by contaminated food
C. Chronic hepatitis can lead to renal cell cancer
,D. Clients who have a history of viral hepatitis are unable to donate blood - Clients who
have a history of viral hepatitis are unable to donate blood
12. A nurse in a residential mental health facility is planning care for a new client who
has obsessive compulsive disorder. Which of the following is appropriate for the nurse
to include in the plan of care?
A. Work with the client to create a flexible daily schedule
B. Gradually decrease the time allowed for ritualistic behavior
C. Offer solutions to assist in problem solving
D. Teach the client to meditate about obsessive thoughts - Work with the client to create
a flexible daily schedule
13. A nurse is assessing an adult male who has a BMI of 20. The nurse should identify
that the client's BMI falls within which of the following categories?
A. Healthy weight
B. Malnutrition
C. Overweight
D. Obesity - Malnutrition
14. A nurse is caring for a client who is nulliparous and in the first stage of labor. The
last internal assessment revealed 100% cervical effacement with 5 cm of dilation. At the
end of the last contraction, the nurse observes a large gush of fluid coming out of the
client's perineal area. Which of the following is a priority action by the nurse?
A. Perform another internal exam
B. Notify the client's provider
C. Check the FHR
D. Obtain a pH test of the fluid - Check the FHR
15. A nurse is creating a plan of care for a client who has anorexia nervosa. Which of
the following interventions should the nurse include in the plan?
A. Encourage the client to gain 2.3 kg per week
B. Weigh the client once per week throughout hospitalization
C. Monitor the client for 1 hr after meals
D. Allow the client to choose meal times - Monitor the client for 1 hr after meals
16. A nurse is performing a skin assessment on a client who has risk factors for
development of skin cancer. The nurse should understand that a suspicious lesion is
A. Asymmetric, with variegated coloring
B. Scaly and red
C. Brown, with a wart-like texture
D. Firm and rubbery - Asymmetric, with variegated coloring
17. A nurse is assessing a client's internal eye structures with an ophthalmoscope.
Which of the following actions should the nurse take?
A. Position the examination light toward the client's face
B. Stand on the right side of the client when examining the left eye
, C. Dim the lights in the room prior to the examination
D. Place the ophthalmoscope directly against the client's forehead - Dim the lights in the
room prior to the examination
18. A nurse is observing a newly licensed nurse irrigate a client's wound. Which of the
following actions should the nurse identify as an indication that the newly licensed nurse
understands wound irrigation?
A. Cleanses the wound with povidone-iodine with cotton balls
B. Administers PO analgesia 20 min prior to irrigation
C. Warms the irrigation solution in the microwave oven prior to application
D. Irrigates the wound from the top to the bottom - Administers PO analgesia 20
minutes prior to irrigation
19. A nurse is planning care for a child who has increased intracranial pressure with a
decrease in level of consciousness. Which of the following interventions should the
nurse include in the plan of care?
A. Perform active range-of-motion exercises
B. Maintain the head at a midline position
C. Suction the airway frequently
D. Perform neurological checks every 4 hrs - Maintain the head at a midline position
20. A nurse notices smoke coming from a client's room and discovers a fire in the
wastebasket. After moving the client to safety, which of the followings is the priority
action?
A. Notify the facility operator
B. Close the fire doors on the unit
C. Turn off oxygen sources
D. Put out the fire with the appropriate extinguisher - Close the fire door on the unit
21. A nurse is talking with an adult child of a client who was involuntarily admitted to an
inpatient mental health facility. Which of the following statements should the nurse
make?
A. The provider will notify your patient's employer about admission to the facility
B. Your parent will have to take the medication that the doctor prescribes
C. Your parent might have electroconvulsive therapy without providing consent
D. The provider can prescribe restraints if your parent tries to harm others - The
provider can prescribe restraints if your parent tries to harm others
22. A nurse is assessing a client who has delirium due to a febrile illness. Which of the
following findings should the nurse expect?
A. Hallucinations
B. Agnosia
C. Bradycardia
D. Aphasia - Hallucinations
