VATI Fundamentals Post-Assessment Actual Exam Questions With Detailed Correct Answers.

A nurse is caring for a client who asks the nurse to explain what advance directives are. Which of the following statements should the nurse make? A. "The health care proxy is a document that explains your wishes for care when you can no longer do so." B. "Be sure that your family agrees with your choices before preparing your advance directives." C. "The provider consults your living will in the event that you are unable to make health care decisions." D. "Be sure you know what you want to write in your advance directives, because you can't change them later." - correct answer C. "The provider consults your living will in the event that you are unable to make health care decisions." Living wills direct care when clients do not have the capacity to make decisions. The provider will review the client's living will and plan treatment according to the client's preferences. A health care proxy is a document that appoints another individual to make health care decisions for the client. Although the family is usually involved, along with the provider, in helping to decide a client's decisional capacity, no one else has to agree with the client's choices. The nurse should instruct the client that they can change their advanced directives at any time. A nurse provides a medical interpreter to convey discharge instructions to a client who speaks a different language than the nurse. This action is an example of which of the following ethical values? A. Advocacy B. Nonmaleficence C. Veracity D. Justice - correct answer A. Advocacy Advocacy is the ethical principle of supporting the client in every situation. The nurse supports this client by using a medical interpreter to ensure that the client understands the discharge teaching. Nonmaleficence is a commitment to do no harm. Although this principle is essential to the practice of nursing, this action is not an example of nonmaleficence. Veracity is telling the truth. Although this principle is essential to the practice of nursing, this action is not an example of veracity. Justice is fairness in care delivery to all clients in order to ensure each client's needs are met. Although this principle is essential to the practice of nursing, this action is not an example of justice. A nurse is reviewing guidelines for documentation in an electronic medical record with a newly licensed nurse. Which of the following information should the nurse include? A. It is important to include personal opinions when documenting assessments. B. Wait until the end of the shift to document an error. C. It is acceptable to document for another nurse in urgent situations. D. Log out of the computer terminal after completing documentation. - correct answer D. Log out of the computer terminal after completing documentation. It is important for the nurse to maintain the security of clients' medical records. Without logging out, others could view or access clients' confidential health information. A nurse receives handoff report on several clients. Which of the following clients is the nurse's priority? A. A client who is postoperative following coronary artery bypass grafting and needs discharge teaching B. A client requiring education about a new prescription for treating asthma C. A client who has a decreased level of consciousness D. A client who is crying after receiving a terminal diagnosis - correct answer C. A client who has a decreased level of consciousness A client who has a decreased level of consciousness is unstable; therefore, this client is the nurse's priority and requires immediate action by the nurse. A nurse is assisting a provider with obtaining informed consent for surgery from a client who is anxious about having the procedure. Which of the following actions should the nurse take? A. Inform the client of the risks and benefits of the surgery. B. Use an interpreter if the client's spoken language is different than the provider's. C. Inform the client that signing the form makes the decision irreversible. D. Make sure the client has received an antianxiety medication before signing the informed consent form. - correct answer B. Use an interpreter if the client's spoken language is different than the provider's. If the provider does not speak the same language as the client, it is essential to have a medical interpreter present to make sure the client understands all aspects of informed consent. Providing information in the client's spoken language is essential in providing safe, competent nursing care. A nurse in the emergency department is caring for a group of clients. The nurse should identify that which of the following tasks is within the nurse's cope of practice? A. Changing the form of a medication for a client who is unable to swallow B. Inserting an endotracheal tube for a client experiencing respiratory distress C. Inserting a subclavian central venous access device D. Inserting a Salem sump tube for gastric decompression - correct answer D. Inserting a Salem sump tube for gastric decompression It is within the scope of nursing practice to insert and maintain an NG tube for removing air and fluid from the stomach. A Salem sump tube is preferable for this purpose. It has two lumina, one for removing stomach contents and the other for providing an air vent. The nurse should contact the provider to change any part of a medication prescription. Changing the form of a medication is beyond the scope of nursing practice. Clinicians who have received specialized training in endotracheal intubation can insert endotracheal tubes. This task is beyond the scope of nursing practice. Providers and advance practice nurses who have received specific training and/or certification can insert subclavian central venous access devices. This task is beyond the scope of nursing practice. Nurses can insert peripherally inserted central catheters (PICCs) with specialized training. A nurse is performing a home safety assessment for a client who had a stroke. The nurse note that the stairs in the client's home are in disrepair and pose a safety risk. The client states, "I cannot afford to have the stairs repaired." Which of the following actions should the nurse take? A. Refer the client to a social worker. B. Provide the client with information about the American Red Cross. C. Ask the client's provider to postpone discharge until the stairs are repaired. D. Recommend a long-term care facility for the client. - correct answer A. Refer the client to a social worker. The nurse should refer the client to a social worker, who can assist a client who is having financial difficulties. The social worker can find resources to repair the stairs. The American Red Cross is a nonprofit organization that provides preparedness education and relief in the event of a disaster. There is no medical indication that warrants postponing the client's discharge. A long-term care facility is indicated for clients who are no longer able to perform their own activities of daily living. There is no indication that warrants recommending a long-term care facility for the client. A nurse is admitting a client who is at risk for falls. Which of the following interventions should the nurse include in the client's plan of care? A. Keep all four side rails in the up position. B. Offer assistance with toileting every 4 hr. C. Place the client's personal possessions in the bedside closet. D. Have the client demonstrate how to use the call light. - correct answer D. Have the client demonstrate how to use the call light. The nurse should demonstrate use of the call light for the client and ask for a return demonstration to confirm the client's understanding. This ensures the client will be able to request assistance quickly and reduces the risk for falls. Evidence-based practice indicates that raised side rails can pose a safety hazard. Clients might still try to get out of bed by climbing over the rails, which can increase the risk of falling. The nurse should make rounds and offe