RN VATI Fundamentals 2019 Assessment
A nurse is preparing to mix short-acting and intermediate-acting insulin in one syringe to administer to a
client who has type 1 diabetes mellitus. Identify the sequence the nurse should follow. Correct Answer:
1: Draw up the volume of insulin from the intermediate-acting insulin vial.
2: Inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting
insulin vial.
3: Inject the volume of air equal to the insulin dose form the short-acting insulin vial
4: Withdraw the prescribed amount of insulin form the short-acting insulin vial.
5: Withdraw the prescribed amount of insulin form the intermediate-acting insulin vial.
A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the following
actions should the nurse take? Correct Answer: Advise the client to rinse their mouth and dentures
after each meal.
A nurse is planning care for a client who has dysphagia and is at risk for aspiration. Which of the
following referrals should the nurse make? Correct Answer: Speech-language pathologist
thoracentesis post procedure? Correct Answer: Position the client on the unaffected side.The nurse
should position the client on the unaffected side to help facilitate expansion of the affected lung.
Maintain the head of the bed at 45°.MY ANSWERSome facility protocols recommend that the nurse
should raise the head of the bed to 30° for at least 30 min to facilitate expansion of the affected lung
and ease of breathing.
Measure the client's abdominal girth at the level of the umbilicus.The nurse should measure the client's
abdominal girth following an abdominal paracentesis, rather than a thoracentesis.
Leave the puncture site open to air.The nurse should apply a small, sterile dressing over the puncture
site.
A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of
the following actions should the nurse take prior to performing the teaching? (select all that apply)
Correct Answer: - Establish the client's learning needs
- Determine the client's literacy level
- Evaluate the client's readiness for learning
- Identify the client's learning style
A nurse is preparing to notify the provider about a change in a client's status. Which of the following
information should the nurse plan to include in the "background" portion of the SBAR communication
tool? Correct Answer: Previous treatments
, A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy
utilizing a compressed oxygen system. Which of the following statements by the client indicates an
understanding of the teaching? Correct Answer: "I will store oxygen tanks in an upright position"
A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I am afraid of
dying." Which of the following responses should the nurse make? Correct Answer: "It must me a very
difficult time for you."
A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an
internal stressor? Correct Answer: Fear of medical test results
A nurse is performing postmortem care for an older client who had just died. Which of the following
actions should the nurse take? Correct Answer: Identify the client using two identifiers
A nurse has administered 5 mL of medication to a client via NG tube. Then used 30 mL of water to flush
the tue both before and after the instillation. the nurse should document which of the following
amounts as liquid intake for the client? Correct Answer: 65 mL
A nurse is performing a family assessment for a client who has recently developed paraplegia following a
stroke. Which of the following actions should the nurse take first? Correct Answer: Determine how the
client views the concept of family
A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following
actions should the nurse take first? Correct Answer: Determine the source of the client's stress
A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the
nurse take to maintain the client's skin integrity? Correct Answer: Use an alcohol-free barrier product
A nurse receives a telephone prescription form the provider, who states, "four milligrams of morphine
diluted with 5 milliliters of sterile water intravenous each morning at nine o'clock before client dressing
changes." Which of the following entries by the nurse indicates correct transcription of the prescription?
Correct Answer: Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute medication with 5
mL of sterile water
how to assess for clonus? Correct Answer: Use a reflex hammer.MY ANSWER
The nurse should use a reflex hammer to assess the client for clonus. The reflex hammer causes the
muscle to immediately contract due to a two-neuron reflex arc involving the spinal or brainstem
segment that innervates the muscle.
Administer magnesium sulfate.Administering magnesium sulfate is not a test for clonus. Magnesium
sulfate is administered for convulsions, hypomagnesemia, and hypertension.
Perform a Romberg test.A Romberg test assesses balance, gross-motor function, and equilibrium.
Test the gait for symmetry.Testing the client's gait gives the nurse information about symmetry, walking
ability, posture, and balance.
A nurse in a long-term care facility is planning to use therapeutic tough for a group of selected clients
who have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for
A nurse is preparing to mix short-acting and intermediate-acting insulin in one syringe to administer to a
client who has type 1 diabetes mellitus. Identify the sequence the nurse should follow. Correct Answer:
1: Draw up the volume of insulin from the intermediate-acting insulin vial.
2: Inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting
insulin vial.
3: Inject the volume of air equal to the insulin dose form the short-acting insulin vial
4: Withdraw the prescribed amount of insulin form the short-acting insulin vial.
5: Withdraw the prescribed amount of insulin form the intermediate-acting insulin vial.
A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the following
actions should the nurse take? Correct Answer: Advise the client to rinse their mouth and dentures
after each meal.
A nurse is planning care for a client who has dysphagia and is at risk for aspiration. Which of the
following referrals should the nurse make? Correct Answer: Speech-language pathologist
thoracentesis post procedure? Correct Answer: Position the client on the unaffected side.The nurse
should position the client on the unaffected side to help facilitate expansion of the affected lung.
Maintain the head of the bed at 45°.MY ANSWERSome facility protocols recommend that the nurse
should raise the head of the bed to 30° for at least 30 min to facilitate expansion of the affected lung
and ease of breathing.
Measure the client's abdominal girth at the level of the umbilicus.The nurse should measure the client's
abdominal girth following an abdominal paracentesis, rather than a thoracentesis.
Leave the puncture site open to air.The nurse should apply a small, sterile dressing over the puncture
site.
A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of
the following actions should the nurse take prior to performing the teaching? (select all that apply)
Correct Answer: - Establish the client's learning needs
- Determine the client's literacy level
- Evaluate the client's readiness for learning
- Identify the client's learning style
A nurse is preparing to notify the provider about a change in a client's status. Which of the following
information should the nurse plan to include in the "background" portion of the SBAR communication
tool? Correct Answer: Previous treatments
, A nurse is providing discharge teaching to a client who has a new prescription for home oxygen therapy
utilizing a compressed oxygen system. Which of the following statements by the client indicates an
understanding of the teaching? Correct Answer: "I will store oxygen tanks in an upright position"
A nurse is caring for a client who has terminal cancer. The client begins to cry and says, "I am afraid of
dying." Which of the following responses should the nurse make? Correct Answer: "It must me a very
difficult time for you."
A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an
internal stressor? Correct Answer: Fear of medical test results
A nurse is performing postmortem care for an older client who had just died. Which of the following
actions should the nurse take? Correct Answer: Identify the client using two identifiers
A nurse has administered 5 mL of medication to a client via NG tube. Then used 30 mL of water to flush
the tue both before and after the instillation. the nurse should document which of the following
amounts as liquid intake for the client? Correct Answer: 65 mL
A nurse is performing a family assessment for a client who has recently developed paraplegia following a
stroke. Which of the following actions should the nurse take first? Correct Answer: Determine how the
client views the concept of family
A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following
actions should the nurse take first? Correct Answer: Determine the source of the client's stress
A nurse is caring for a client who had a stroke and is immobile. Which of the following actions should the
nurse take to maintain the client's skin integrity? Correct Answer: Use an alcohol-free barrier product
A nurse receives a telephone prescription form the provider, who states, "four milligrams of morphine
diluted with 5 milliliters of sterile water intravenous each morning at nine o'clock before client dressing
changes." Which of the following entries by the nurse indicates correct transcription of the prescription?
Correct Answer: Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute medication with 5
mL of sterile water
how to assess for clonus? Correct Answer: Use a reflex hammer.MY ANSWER
The nurse should use a reflex hammer to assess the client for clonus. The reflex hammer causes the
muscle to immediately contract due to a two-neuron reflex arc involving the spinal or brainstem
segment that innervates the muscle.
Administer magnesium sulfate.Administering magnesium sulfate is not a test for clonus. Magnesium
sulfate is administered for convulsions, hypomagnesemia, and hypertension.
Perform a Romberg test.A Romberg test assesses balance, gross-motor function, and equilibrium.
Test the gait for symmetry.Testing the client's gait gives the nurse information about symmetry, walking
ability, posture, and balance.
A nurse in a long-term care facility is planning to use therapeutic tough for a group of selected clients
who have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for
