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RN VATI Fundamentals 2025 Assessment
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Version 2025 | 100% Verified
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. - ✔✔ 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. To mix insulin from two vials in the same syringe, the nurse should first draw up a volume of air equal to the volume of insulin from the intermediate-acting insulin vial. The nurse should then inject the volume of air equal to the amount of insulin to withdraw from the intermediate-acting insulin vial, making sure the needle does not touch the insulin. Next, the nurse should inject the volume of air equal to the insulin dose from the short-acting insulin vial. Then, the nurse should withdraw the prescribed amount of insulin from the short-acting insulin vial. Lastly, the nurse should withdraw the prescribed amount of insulin from the intermediate-acting insulin vial. The insulins are now mixed and ready to administer. A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the following actions should the nurse take? - ✔✔Advise the client to rinse their mouth and dentures after each meal. The nurse should advise the client to rinse their mouth and dentures after each meal to remove food and particles and to promote healing of gums and oral mucosa. 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? - ✔✔Speech-language pathologist
The nurse should recommend a referral for a client who has dysphagia to a speech-language pathologist. Clients who have dysphagia have difficulty swallowing and are at risk for aspiration. The speech-language pathologist can perform a swallow study to determine the extent of the client's dysphagia and work with the client to develop new swallowing techniques. 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) - ✔✔- 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 Establish the client's learning needs is correct. Prior to planning any teaching session, the nurse should perform a comprehensive assessment of the client's learning needs. This assessment incorporates information from the client's history and physical assessment, current health problems, understanding of and adherence to the prescribed treatment plan, and support system. Determine the client's literacy level is correct. Knowing the client's literacy level is an important factor in communicating with the client and in delivering audiovisual presentations and written materials. If the client cannot understand the information the nurse presents, they will not learn. Evaluate the client's readiness for learning is correct. The nurse should determine the client's physical readiness (pain control), emotional readiness (acceptance of diagnosis), and cognitive readiness (appropriate level of consciousness). Identify the client's learning style is correct. The best way to learn varies from client to client. Some people learn best by watching a demonstration, while others thrive in a group setting, and others prefer to read information on their own. In a group setting, the nurse should use a variety of styles to accommodate most learners. 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? - ✔✔Previous treatments The nurse should include previous treatments in the "background" portion of the SBAR communication tool. Other information the nurse should include in the "background" portion is the client's admission history, diagnosis, pertinent medical history, and code status.
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? - ✔✔ 65 mL A client who has an NG tube can receive numerous liquid medications, plus water to flush the tube before and after medications. Over a 24 - hr period, these liquids can amount to a significant intake. The nurse should document them on the intake and output record. A value of 65 mL accounts for 5 mL of medication and two 30 - mL flushes. 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? - ✔✔Determine how the client views the concept of family According to evidence-based practice, the nurse should first determine how the client views the concept of a family. This will influence the nurse's decision on how or whether to move forward in including the family into the client's plan of care. 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? - ✔✔Determine the source of the client's stress The first action the nurse should take when using the nursing process is to assess or determine what is causing the client to experience increased 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? - ✔✔Use an alcohol-free barrier product The nurse should apply an alcohol-free barrier film to keep the client's skin dry and protect it from the collection of moisture. This action will help to maintain the integrity of the client's skin. 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?
- ✔✔Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute medication with 5 mL of sterile water
This entry by the nurse indicates correct transcription of the prescription. This transcription contains acceptable abbreviations according to The Joint Commission and includes complete information from the provider. 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 which of the following patients? - ✔✔A client who has chronic back pain and a history of physical maltreatment Therapeutic touch consists of using the nurse's hands to harmonize energy fields and to facilitate relief of pain or anxiety, such as for a client who has chronic back pain. The nurse can touch the client with their palms or move the palms near, but not touching the client's body. Prior physical maltreatment and some mental health disorders are contraindications for therapeutic touch, because touch or near touch could cause severe anxiety. A nurse is preparing to delegate task for multiple clients at the beginning of the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? - ✔✔Assist a client with ambulation When delegating client care activities to an AP, the delegating nurse should follow the five rights of delegation, which include right task, right circumstance, right person, right direction, and right evaluation. Assisting a client with ambulation is within the range of function of an AP. A home health nurse is making an initial assessment visit to an older client who has type 1 diabetes mellitus. Which of the following statements should the nurse make to evaluate the clients ability ot measure blood glucose accurately? - ✔✔"Please use your glucometer and show me the results." Asking for a return demonstration is an effective way to assess a client's ability to complete a psychomotor activity. The nurse should carefully observe the client using the glucometer to validate the client's understanding of the procedure and evaluate whether or not the method is accurate. A nurse is caring for a client who has an ankle sprain and a prescription for an aquathermia pad. Which of the following actions should the nurse take? - ✔✔Cover the pad with a pillowcase before application.
A nurse is evaluating preoperative teaching with a client who is to undergo surgery with general anesthesia. Which of the following statements by the client indicates an understanding of the teaching? - ✔✔"I should remove nail polish form my fingers before surgery." The nurse should instruct the client to remove nail polish for accurate pulse oximetry monitoring and for a clear view of the nail beds when assessing capillary refill. A nurse is moving a client up in bed with assistance of another nurse. Which of the following actions should the nurse take? - ✔✔Positions the client's arms across their chest. The nurse should position the client's arms across their chest to minimize friction during movement and prevent injury. RN in a rehab unit is assessing a group of clients who have a TBI. The RN should identify that which of the following clients requires a priority referral? - ✔✔A client who consistently coughs after drinking liquids The greatest risk to this client is injury from aspiration. Therefore, this is the client the nurse should address first. The priority referral the nurse should make is to a speech-language pathologist because a client who coughs after drinking liquids is at risk for aspiration. Manifestations of dysphagia include changes in voice tone, coughing, delayed swallowing, pocketing of food, and occasional silent aspiration, which can occur if a client is experiencing a decrease in sensation. A RN is assessing a client who has hypokalemia. Which of the following findings should the NR expect? - ✔✔Decreased bowel sounds Decreased bowel sounds are an indication of hypokalemia because of decreased excitability of cells, resulting in less responsiveness to normal stimuli in nerves and muscles. RN is preparing to assess a client's cardiac function by auscultating heart sounds at the pulmonic landmarks. Which of the following areas should the RN identify as the pulmonic area? (hotspot question)
- ✔✔C (left sternal border, second intercostal space)
The nurse should identify that this is the pulmonic area of the cardiac landmarks, which is located at the left second intercostal space, near the sternum. RN is assessing a client who has an NG tube and is receiving continuous enteral feedings. The nurse auscultates coarse crackles in the client's lungs. After discontinuing the feeding, which actions should the RN take next? - ✔✔Position the client on their side The greatest risk to this client is aspiration from possible dislodgment of the NG tube and aspirated stomach contents into the respiratory tract. Therefore, the priority nursing action to decrease exacerbation of the condition is to position the client on their side. A RN is applying a new transdermal patch to a client. Which of the following actions should the RN take?
- ✔✔Wear gloves when applying the patch The nurse should apply the patch while wearing clean gloves to prevent transfer of the medication through the skin. A RN is reviewing the medical record of a client is postoperative. Based on the info in the medical record, which of the following actions should the RN take first? - ✔✔Obtain a RX for IV fluids The greatest risk to this client is injury from fluid volume deficit. Therefore, the first action the nurse should take is to contact the provider for a prescription to initiate IV fluid infusion. The client has assessment findings that indicate fluid volume deficit, such as an increased urine specific gravity, a decreased blood pressure, an increased temperature, and a weak pulse. The client also has increased fluid output with decreased intake as well as concentrated urine. To prevent further fluid volume deficit, the nurse's priority action is to administer IV fluids to the client. A RN is assessing an older adult client who has become increasingly confused and agitated in the last 48 hrs. Which of the following conditions should the nurse expect? - ✔✔UTI According to evidence-based practice, the nurse should expect the client who has a urinary tract infection to become increasingly confused and agitated. Confusion and agitation in older adult clients often result from a systemic infection, such as a urinary tract infection or pneumonia.
The first action the nurse should take when using the nursing process is to assess the methods that the client used to successfully cope with other issues in the past and then reinforce them. This will help encourage the client to begin to learn self-care. A RN manager is teaching a group of newly licensed RN's about procedures are within their scope of practice. Which if the following examples should the RN include in the teaching? - ✔✔Monitoring a continuous intra-arterial infusion of a thrombolytic medication Monitoring the infusion of a clot-dissolving agent is within a nurse's scope of practice. In addition, the nurse should inspect the IV line for a disconnection, check the infusion site for bleeding, and maintain site integrity. A RN is completing a preadmission interview for a client who is ti undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the RN include when planning care for the client's surgery? - ✔✔-Notify ancillary dept. of the client's allergy
- Label the surgical suite as latex-free
- Ensure a latex allergy care is available Notify ancillary departments of the client's allergy is correct. Notifying ancillary departments of the client's sensitivity to latex allows the staff to take appropriate measures to ensure that medications and surgical items are not contaminated by latex. Label the surgical suite as latex-free is correct. This helps keep personnel from bringing rubber products into the room. Ensure a latex allergy cart is available is correct. A latex allergy cart should be kept in the operating room at all times. All of the contents must be latex-free. A school RN is teaching a group of parents about measures to prevent firearm injuries in the home. Which of the following instructions should the nurse include in the teaching? - ✔✔"Keep ammunition and guns in separate, locked locations." The nurse should instruct the parents to keep ammunition in a locked cabinet separate from the firearms to reduce the risk for injury. This action will prevent access to the firearm and also prevents injury from accidental discharge because the firearm does not contain ammunition. Also, the keys to the cabinet should not be accessible to children.
A RN is caring for a client who has terminal illness. The client request a DNR order, but their family opposes the decision. Which of the following actions should the nurse take first. - ✔✔Gather information to support the client's request for a DNR order Using the nursing process, the first action the nurse should take is to assess the situation by gathering information to support the client's request for a DNR order. This information should include the client's current clinical status, factors such as the client's spirituality, culture, and family dynamics, and evidence from literature about the client's condition. a home health nurse is performing a home assessment for an older adult client. which of the following statements by the client should alert the nurse to suggest additional safety measures? - ✔✔"I use space heaters to keep warm in the winter." A common environmental hazard in the home is the use of space heaters, which can increase the risk of fire. a nurse is preparing to administer an intramuscular injection to a client. at which of the following angles should the nurse plan to insert the needle - ✔✔ 90 The nurse should plan to insert the needle at a 90 ° angle when administering medication via the intramuscular route. The intramuscular route promotes quicker medication absorption into the muscle than the other routes of medication administration.
