VATI: FUNDAMENTALS - PRE-ASSESSMENT
QUIZ /ACCURATE RESPONSE /LATEST
24/25
1. A nurse is caring for a client who has returned to the unit following a sur- gical
procedure. The client's oxygen saturation is 85%. Which of the following actions should
the nurse take first ?
A. Administer O2 at 2L/min
B. Administer prescribed analgesic med
C. Encourage coughing and deep breathing
D. Raise the head of the bed: D. Raise the head of the bed
Elevating the head of the bed uses gravity to reduce pressure on the
diaphragm from the abdominal organs and allows for increased
expansion of the lungs. The head and neck can be extended, which
promotes a patent airway. This is the first action the nurse should take
and is the least invasive.
A. The nurse should assess the client further and implement less
invasive interven- tions before applying oxygen at 2 L/min.
B.Pain management promotes increased participation by the client in
coughing and deep breathing, frequent position changes and use of the
incentive spirometer, but this is not the first action the nurse should
take.
C. Coughing and deep breathing promotes lung expansion and prevents
respiratory infection, but these actions are not effective immediately in
increasing oxygen saturation.
2. A nurse is providing teaching to a client who has neutropenia. Which of the
following information should the nurse include in the teaching?
A. Eat plenty of fresh fruits and vegetables
B. Avoid crowds
C. Perform mild exercise, such as gardening
D. Take temperatures weekly: B. Avoid crowds
,The nurse should inform the client to avoid crowds due to his
suppressed immune system.
A. The nurse should inform a client who is neutropenic to avoid fresh
fruits and vegetables due to the bacteria they can carry.
C. The nurse should instruct the client to avoid gardening due bacteria
contained in the soil.
D. A client who is neutropenic can experience a 1° increase from his
baseline tem- perature, even in the presence of infection. Therefore, the
nurse should recommend the client take his temperature at least once
daily.
3. A nurse is assessing a client following the application of an aquathermia pad.
Which of the following is the first indication to the nurse that the client is experiencing
a superficial burn injury to the application site?
A. Blistering
B. Erythema
C. Eschar
D. Absence of pain: B. Erythema
Erythema is an indication that the client has experienced a superficial
burn with damage limited to the epidermis. Other manifestations
include edema, pain, and increased sensitivity to heat.
A. Blistering is an indication of a superficial partial thickness burn,
involving injury to the upper third of the dermis. These injuries also are
pink and moist, blanch to pressure and are very painful.
C. Eschar is seen in clients who have a full thickness wound involving
the epidermis and dermis. This is dead tissue that must be removed for
healing to occur
D. A thermal injury that is not painful can be classified as a deep full-
thickness burn which extends into muscle, bone, or tendons.
4. A nurse in a long-tern care facility enters the day room and finds the window
curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the
emergency actions the nurse must take.
, Activate the fire
alarm. Extinguish the
fire.
Close the door.
Remove the clients from the room.: Remove the clients from the room.
Activate the fire alarm.
Close the door.
Extinguish the
fire.
In the event of a fire, it is helpful to recall the mnemonic RACE to
prioritize the actions to take: R - Rescue and remove the clients, A -
Activate the alarm, C - Confine the fire, and E - Extinguish the fire. The
nurse's priority action is to remove the clients from the room. The nurse
should then sound the fire alarm and close the door to confine the fire.
Finally and if possible, the nurse should extinguish the fire.
5. A nurse is developing a plan of care for a client who is postoperative. Which of the
following interventions should the nurse include in the plan of prevent pulmonary
complications?
A. Perform ROM exercises
B. Place suction equipment at the bedside
C. Encourage the use of an incentive spirometer
D. Administer an expectorant: C. Encourage the use of an incentive
spirometer.
Incentive spirometry expands the lungs and promotes gas exchange
after surgery which can help prevent pulmonary complications.
A. This is not indicated to prevent pulmonary complications, but early
ambulation is helpful to promote lung expansion and remove
secretions.
B. Suction equipment should be readily available if needed, but its
presence does not prevent pulmonary complications.
QUIZ /ACCURATE RESPONSE /LATEST
24/25
1. A nurse is caring for a client who has returned to the unit following a sur- gical
procedure. The client's oxygen saturation is 85%. Which of the following actions should
the nurse take first ?
A. Administer O2 at 2L/min
B. Administer prescribed analgesic med
C. Encourage coughing and deep breathing
D. Raise the head of the bed: D. Raise the head of the bed
Elevating the head of the bed uses gravity to reduce pressure on the
diaphragm from the abdominal organs and allows for increased
expansion of the lungs. The head and neck can be extended, which
promotes a patent airway. This is the first action the nurse should take
and is the least invasive.
A. The nurse should assess the client further and implement less
invasive interven- tions before applying oxygen at 2 L/min.
B.Pain management promotes increased participation by the client in
coughing and deep breathing, frequent position changes and use of the
incentive spirometer, but this is not the first action the nurse should
take.
C. Coughing and deep breathing promotes lung expansion and prevents
respiratory infection, but these actions are not effective immediately in
increasing oxygen saturation.
2. A nurse is providing teaching to a client who has neutropenia. Which of the
following information should the nurse include in the teaching?
A. Eat plenty of fresh fruits and vegetables
B. Avoid crowds
C. Perform mild exercise, such as gardening
D. Take temperatures weekly: B. Avoid crowds
,The nurse should inform the client to avoid crowds due to his
suppressed immune system.
A. The nurse should inform a client who is neutropenic to avoid fresh
fruits and vegetables due to the bacteria they can carry.
C. The nurse should instruct the client to avoid gardening due bacteria
contained in the soil.
D. A client who is neutropenic can experience a 1° increase from his
baseline tem- perature, even in the presence of infection. Therefore, the
nurse should recommend the client take his temperature at least once
daily.
3. A nurse is assessing a client following the application of an aquathermia pad.
Which of the following is the first indication to the nurse that the client is experiencing
a superficial burn injury to the application site?
A. Blistering
B. Erythema
C. Eschar
D. Absence of pain: B. Erythema
Erythema is an indication that the client has experienced a superficial
burn with damage limited to the epidermis. Other manifestations
include edema, pain, and increased sensitivity to heat.
A. Blistering is an indication of a superficial partial thickness burn,
involving injury to the upper third of the dermis. These injuries also are
pink and moist, blanch to pressure and are very painful.
C. Eschar is seen in clients who have a full thickness wound involving
the epidermis and dermis. This is dead tissue that must be removed for
healing to occur
D. A thermal injury that is not painful can be classified as a deep full-
thickness burn which extends into muscle, bone, or tendons.
4. A nurse in a long-tern care facility enters the day room and finds the window
curtains on fire. Clients are panicking and the room is filling with smoke. Indicate the
emergency actions the nurse must take.
, Activate the fire
alarm. Extinguish the
fire.
Close the door.
Remove the clients from the room.: Remove the clients from the room.
Activate the fire alarm.
Close the door.
Extinguish the
fire.
In the event of a fire, it is helpful to recall the mnemonic RACE to
prioritize the actions to take: R - Rescue and remove the clients, A -
Activate the alarm, C - Confine the fire, and E - Extinguish the fire. The
nurse's priority action is to remove the clients from the room. The nurse
should then sound the fire alarm and close the door to confine the fire.
Finally and if possible, the nurse should extinguish the fire.
5. A nurse is developing a plan of care for a client who is postoperative. Which of the
following interventions should the nurse include in the plan of prevent pulmonary
complications?
A. Perform ROM exercises
B. Place suction equipment at the bedside
C. Encourage the use of an incentive spirometer
D. Administer an expectorant: C. Encourage the use of an incentive
spirometer.
Incentive spirometry expands the lungs and promotes gas exchange
after surgery which can help prevent pulmonary complications.
A. This is not indicated to prevent pulmonary complications, but early
ambulation is helpful to promote lung expansion and remove
secretions.
B. Suction equipment should be readily available if needed, but its
presence does not prevent pulmonary complications.
