RN VATI Medical-Surgical Nursing
Q1. The nurse is caring for four patients on a medical-surgical unit. Which patient should the
nurse assess first?
A) A 72-year-old with pneumonia, oxygen saturation of 91% on 2 L nasal cannula, and a
respiratory rate of 22/min
B) A 65-year-old with heart failure who has 3+ pitting edema and crackles in the lung bases
C) A 55-year-old with a pulmonary embolism on a heparin drip who is reporting sudden, severe
back pain and abdominal distension
D) A 48-year-old with diabetes and a blood glucose of 210 mg/dL who is reporting increased
thirst
E) A 60-year-old post-operative day 2 from a total knee replacement with a temperature of
38.2°C (100.8°F)
Detailed Answer:
Correct Answer: C
The patient with a pulmonary embolism on a heparin drip who reports sudden severe back pain
and abdominal distension is exhibiting signs of retroperitoneal bleeding, a life-threatening
complication of anticoagulation. This requires immediate assessment and intervention. The
other patients have urgent but not immediately life-threatening issues: oxygen saturation of
91% (A) is acceptable on oxygen, heart failure with edema (B) is expected, hyperglycemia (D)
can be managed, and a low-grade fever (E) is common post-operatively.
Q2. The nurse is delegating tasks to a licensed practical nurse (LPN) and a nursing assistant
(UAP). Which of the following tasks is most appropriate for the nurse to delegate to the LPN?
A) Obtaining a blood glucose reading from a patient with diabetes
B) Administering an enteral feeding via a gastrostomy tube
C) Performing a comprehensive admission assessment on a new patient
D) Teaching a patient how to self-administer insulin
E) Changing a sterile dressing on a central line
Detailed Answer:
Correct Answer: B
LPNs can administer enteral feedings (via gastrostomy or nasogastric tube) and perform many
technical skills. Obtaining a blood glucose (A) is appropriate for a UAP. Comprehensive
assessment (C) and teaching (D) must be performed by the RN. Changing a sterile dressing on a
central line (E) may be within the LPN's scope but is more complex and often reserved for RNs;
however, tube feeding is the most standard and safest LPN task.
,Q3. A patient with a terminal illness is admitted to the medical-surgical unit. The patient has a
do-not-resuscitate (DNR) order. The patient's family requests that the DNR be reversed. What
is the nurse's most appropriate action?
A) Immediately reverse the DNR order
B) Consult the ethics committee
C) Ask the patient if they want the DNR reversed
D) Notify the healthcare provider and request a new order
E) Continue to follow the DNR order
Detailed Answer:
Correct Answer: D
A DNR order cannot be reversed by the family or the nurse; it requires a new order from the
healthcare provider. The nurse should notify the provider to discuss the family's request. The
patient's wishes (if they are able to express them) and the family's concerns should be
addressed through the provider. Option E (continuing the DNR) is correct until a new order is
written, but notifying the provider is the most appropriate action.
Q4. The nurse is preparing to administer a blood transfusion to a patient. The patient has a
history of a febrile non-hemolytic transfusion reaction. Which of the following pre-
medications is most likely to be ordered?
A) Acetaminophen (Tylenol)
B) Diphenhydramine (Benadryl)
C) Methylprednisolone (Solu-Medrol)
D) Furosemide (Lasix)
E) Hydrocortisone
Detailed Answer:
Correct Answer: A
For a patient with a history of febrile non-hemolytic transfusion reactions, pre-medication with
acetaminophen (antipyretic) is standard. Diphenhydramine (B) is used for allergic reactions.
Corticosteroids (C/E) are for severe allergic or hemolytic reactions. Furosemide (D) is for volume
overload.
Q5. The nurse is caring for a patient with a nasogastric (NG) tube set to low intermittent
suction. The patient reports nausea and abdominal distension. The nurse should first:
A) Irrigate the NG tube with 50 mL of normal saline
,B) Check the placement of the NG tube
C) Increase the suction pressure
D) Administer an antiemetic
E) Remove the NG tube
Detailed Answer:
Correct Answer: B
Nausea and distension with an NG tube suggest that the tube may be dislodged or clogged. The
first action is to check placement (by auscultating the air bolus or checking pH of aspirate) to
ensure the tube is in the stomach. Irrigating (A) is done if the tube is patent but clogged.
Increasing suction (C) is not the first step. Antiemetics (D) may be given later. Removing the tube
(E) is not indicated.
Q6. The nurse is caring for a patient who is receiving a continuous heparin infusion. The
patient's aPTT is 110 seconds (normal 25-35 seconds). What is the nurse's priority action?
A) Stop the infusion and notify the healthcare provider
B) Decrease the rate and monitor
C) Increase the rate to achieve therapeutic levels
D) Administer protamine sulfate
E) Continue the infusion and reassess in 4 hours
Detailed Answer:
Correct Answer: A
The therapeutic aPTT for heparin is typically 1.5-2.5 times the normal (approximately 60-80
seconds). An aPTT of 110 seconds is significantly elevated and indicates a high bleeding risk. The
nurse should stop the infusion and notify the provider. Decreasing the rate (B) is an alternative
but stopping is safer until the provider orders a new rate. Protamine sulfate (D) is for bleeding.
Q7. A patient with an indwelling urinary catheter has a urine output of 25 mL/hr. What is the
nurse's initial action?
A) Increase the patient's IV fluid rate
B) Notify the healthcare provider
C) Assess the patency of the catheter
D) Administer a diuretic
E) Obtain a urine culture
Detailed Answer:
Correct Answer: C
, A urine output of <30 mL/hr is oliguria. The nurse should first assess the patency of the catheter
(check for kinks, ensure the tubing is not clamped, assess for sediment or clots). Only after
patency is confirmed should other actions be taken. Increasing fluids (A) or notifying the
provider (B) are subsequent actions. Diuretics (D) are not indicated without assessment.
Q8. The nurse is caring for a patient with a new colostomy. Which of the following findings is
most concerning and requires immediate notification of the healthcare provider?
A) The stoma is pink, moist, and slightly raised
B) The stoma is purple and dry
C) The stoma is producing liquid stool
D) The skin around the stoma is red and excoriated
E) The stoma is bleeding slightly from the tip
Detailed Answer:
Correct Answer: B
A purple, dry, or dark stoma indicates ischemia or necrosis and requires immediate notification
of the surgeon. A pink, moist stoma (A) is healthy. Liquid stool (C) is expected for a new
colostomy. Skin irritation (D) is common and can be managed. Slight bleeding from the tip (E) is
expected postoperatively.
Q9. The nurse is evaluating a patient's understanding of a low-sodium diet for heart failure.
Which of the following statements indicates the patient needs further teaching?
A) "I will avoid canned soups and processed meats."
B) "I will use fresh herbs and spices instead of salt."
C) "I can still use salt substitutes that contain potassium."
D) "I will limit my intake of bread and cereals."
E) "I will check food labels for sodium content."
Detailed Answer:
Correct Answer: C
Salt substitutes often contain potassium and can cause hyperkalemia, especially in patients with
heart failure who may be on potassium-sparing diuretics or have renal impairment. The patient
should be taught to avoid salt substitutes unless approved by the provider. The other
statements are correct for a low-sodium diet.
Q1. The nurse is caring for four patients on a medical-surgical unit. Which patient should the
nurse assess first?
A) A 72-year-old with pneumonia, oxygen saturation of 91% on 2 L nasal cannula, and a
respiratory rate of 22/min
B) A 65-year-old with heart failure who has 3+ pitting edema and crackles in the lung bases
C) A 55-year-old with a pulmonary embolism on a heparin drip who is reporting sudden, severe
back pain and abdominal distension
D) A 48-year-old with diabetes and a blood glucose of 210 mg/dL who is reporting increased
thirst
E) A 60-year-old post-operative day 2 from a total knee replacement with a temperature of
38.2°C (100.8°F)
Detailed Answer:
Correct Answer: C
The patient with a pulmonary embolism on a heparin drip who reports sudden severe back pain
and abdominal distension is exhibiting signs of retroperitoneal bleeding, a life-threatening
complication of anticoagulation. This requires immediate assessment and intervention. The
other patients have urgent but not immediately life-threatening issues: oxygen saturation of
91% (A) is acceptable on oxygen, heart failure with edema (B) is expected, hyperglycemia (D)
can be managed, and a low-grade fever (E) is common post-operatively.
Q2. The nurse is delegating tasks to a licensed practical nurse (LPN) and a nursing assistant
(UAP). Which of the following tasks is most appropriate for the nurse to delegate to the LPN?
A) Obtaining a blood glucose reading from a patient with diabetes
B) Administering an enteral feeding via a gastrostomy tube
C) Performing a comprehensive admission assessment on a new patient
D) Teaching a patient how to self-administer insulin
E) Changing a sterile dressing on a central line
Detailed Answer:
Correct Answer: B
LPNs can administer enteral feedings (via gastrostomy or nasogastric tube) and perform many
technical skills. Obtaining a blood glucose (A) is appropriate for a UAP. Comprehensive
assessment (C) and teaching (D) must be performed by the RN. Changing a sterile dressing on a
central line (E) may be within the LPN's scope but is more complex and often reserved for RNs;
however, tube feeding is the most standard and safest LPN task.
,Q3. A patient with a terminal illness is admitted to the medical-surgical unit. The patient has a
do-not-resuscitate (DNR) order. The patient's family requests that the DNR be reversed. What
is the nurse's most appropriate action?
A) Immediately reverse the DNR order
B) Consult the ethics committee
C) Ask the patient if they want the DNR reversed
D) Notify the healthcare provider and request a new order
E) Continue to follow the DNR order
Detailed Answer:
Correct Answer: D
A DNR order cannot be reversed by the family or the nurse; it requires a new order from the
healthcare provider. The nurse should notify the provider to discuss the family's request. The
patient's wishes (if they are able to express them) and the family's concerns should be
addressed through the provider. Option E (continuing the DNR) is correct until a new order is
written, but notifying the provider is the most appropriate action.
Q4. The nurse is preparing to administer a blood transfusion to a patient. The patient has a
history of a febrile non-hemolytic transfusion reaction. Which of the following pre-
medications is most likely to be ordered?
A) Acetaminophen (Tylenol)
B) Diphenhydramine (Benadryl)
C) Methylprednisolone (Solu-Medrol)
D) Furosemide (Lasix)
E) Hydrocortisone
Detailed Answer:
Correct Answer: A
For a patient with a history of febrile non-hemolytic transfusion reactions, pre-medication with
acetaminophen (antipyretic) is standard. Diphenhydramine (B) is used for allergic reactions.
Corticosteroids (C/E) are for severe allergic or hemolytic reactions. Furosemide (D) is for volume
overload.
Q5. The nurse is caring for a patient with a nasogastric (NG) tube set to low intermittent
suction. The patient reports nausea and abdominal distension. The nurse should first:
A) Irrigate the NG tube with 50 mL of normal saline
,B) Check the placement of the NG tube
C) Increase the suction pressure
D) Administer an antiemetic
E) Remove the NG tube
Detailed Answer:
Correct Answer: B
Nausea and distension with an NG tube suggest that the tube may be dislodged or clogged. The
first action is to check placement (by auscultating the air bolus or checking pH of aspirate) to
ensure the tube is in the stomach. Irrigating (A) is done if the tube is patent but clogged.
Increasing suction (C) is not the first step. Antiemetics (D) may be given later. Removing the tube
(E) is not indicated.
Q6. The nurse is caring for a patient who is receiving a continuous heparin infusion. The
patient's aPTT is 110 seconds (normal 25-35 seconds). What is the nurse's priority action?
A) Stop the infusion and notify the healthcare provider
B) Decrease the rate and monitor
C) Increase the rate to achieve therapeutic levels
D) Administer protamine sulfate
E) Continue the infusion and reassess in 4 hours
Detailed Answer:
Correct Answer: A
The therapeutic aPTT for heparin is typically 1.5-2.5 times the normal (approximately 60-80
seconds). An aPTT of 110 seconds is significantly elevated and indicates a high bleeding risk. The
nurse should stop the infusion and notify the provider. Decreasing the rate (B) is an alternative
but stopping is safer until the provider orders a new rate. Protamine sulfate (D) is for bleeding.
Q7. A patient with an indwelling urinary catheter has a urine output of 25 mL/hr. What is the
nurse's initial action?
A) Increase the patient's IV fluid rate
B) Notify the healthcare provider
C) Assess the patency of the catheter
D) Administer a diuretic
E) Obtain a urine culture
Detailed Answer:
Correct Answer: C
, A urine output of <30 mL/hr is oliguria. The nurse should first assess the patency of the catheter
(check for kinks, ensure the tubing is not clamped, assess for sediment or clots). Only after
patency is confirmed should other actions be taken. Increasing fluids (A) or notifying the
provider (B) are subsequent actions. Diuretics (D) are not indicated without assessment.
Q8. The nurse is caring for a patient with a new colostomy. Which of the following findings is
most concerning and requires immediate notification of the healthcare provider?
A) The stoma is pink, moist, and slightly raised
B) The stoma is purple and dry
C) The stoma is producing liquid stool
D) The skin around the stoma is red and excoriated
E) The stoma is bleeding slightly from the tip
Detailed Answer:
Correct Answer: B
A purple, dry, or dark stoma indicates ischemia or necrosis and requires immediate notification
of the surgeon. A pink, moist stoma (A) is healthy. Liquid stool (C) is expected for a new
colostomy. Skin irritation (D) is common and can be managed. Slight bleeding from the tip (E) is
expected postoperatively.
Q9. The nurse is evaluating a patient's understanding of a low-sodium diet for heart failure.
Which of the following statements indicates the patient needs further teaching?
A) "I will avoid canned soups and processed meats."
B) "I will use fresh herbs and spices instead of salt."
C) "I can still use salt substitutes that contain potassium."
D) "I will limit my intake of bread and cereals."
E) "I will check food labels for sodium content."
Detailed Answer:
Correct Answer: C
Salt substitutes often contain potassium and can cause hyperkalemia, especially in patients with
heart failure who may be on potassium-sparing diuretics or have renal impairment. The patient
should be taught to avoid salt substitutes unless approved by the provider. The other
statements are correct for a low-sodium diet.
