RN VATI Adult Medical-Surgical Assessment
Exam 2 Exam Questions and Answers with
Rationales Latest Version Top Rated
Question 1
A nurse is caring for a client admitted with heart failure. Which assessment finding indicates
fluid volume excess?
A. Flat neck veins when sitting upright
B. Crackles heard in both lung bases
C. Dry mucous membranes
D. Increased hematocrit
Correct Answer: B. Crackles heard in both lung bases
Rationale
Heart failure causes decreased cardiac output and fluid backs up into the pulmonary circulation,
leading to pulmonary edema.
• B is correct: Crackles indicate fluid accumulation in the alveoli.
• A: Flat neck veins suggest hypovolemia.
• C: Dry mucous membranes indicate dehydration.
• D: Elevated hematocrit is usually associated with fluid deficit.
Nursing Tip:
Always assess lung sounds, oxygen saturation, daily weights, and edema in clients with heart
failure.
Question 2
A nurse is assessing a client with chronic kidney disease. Which laboratory finding should the
nurse expect?
,A. Low serum creatinine
B. Elevated BUN
C. Low potassium
D. Increased calcium
Correct Answer: B. Elevated BUN
Rationale
Kidneys are unable to excrete nitrogenous wastes effectively.
Typical findings include:
• Elevated BUN
• Elevated creatinine
• Hyperkalemia
• Hyperphosphatemia
• Hypocalcemia
Question 3
A client suddenly develops unilateral weakness, facial droop, and slurred speech. What is the
nurse's priority action?
A. Obtain blood glucose
B. Encourage oral fluids
C. Place the client in Trendelenburg position
D. Administer aspirin immediately
Correct Answer: A. Obtain blood glucose
Rationale
Hypoglycemia can mimic stroke symptoms.
The nurse should rapidly assess blood glucose while activating the stroke protocol.
, • A is correct
• Aspirin should not be administered until hemorrhagic stroke has been ruled out.
Question 4
A client with COPD is receiving oxygen at 6 L/min via nasal cannula. Which assessment finding
requires immediate intervention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 91%
C. Increasing drowsiness
D. Productive cough
Correct Answer: C. Increasing drowsiness
Rationale
High oxygen concentrations can suppress respiratory drive in some clients with COPD, leading
to carbon dioxide retention.
Signs include:
• Drowsiness
• Confusion
• Headache
• Decreased respiratory effort
Question 5
A nurse is caring for a client after thyroidectomy. Which assessment finding indicates possible
hypocalcemia?
A. Bradycardia
B. Positive Chvostek sign
C. Hypertension
, D. Hyperglycemia
Correct Answer: B. Positive Chvostek sign
Rationale
Accidental injury to the parathyroid glands may result in hypocalcemia.
Manifestations include:
• Chvostek sign
• Trousseau sign
• Muscle cramps
• Tetany
• Laryngeal stridor
Question 6
A client reports crushing substernal chest pain radiating to the left arm. Which medication should
the nurse anticipate administering first?
A. Morphine
B. Nitroglycerin
C. Atorvastatin
D. Metoprolol
Correct Answer: B. Nitroglycerin
Rationale
Nitroglycerin dilates coronary arteries and decreases myocardial oxygen demand.
Standard acute coronary syndrome treatment often follows the MONA concept (Morphine,
Oxygen as indicated, Nitroglycerin, Aspirin), with current practice tailoring oxygen to
hypoxemia.
The nurse should first assess blood pressure before administering nitroglycerin.
Exam 2 Exam Questions and Answers with
Rationales Latest Version Top Rated
Question 1
A nurse is caring for a client admitted with heart failure. Which assessment finding indicates
fluid volume excess?
A. Flat neck veins when sitting upright
B. Crackles heard in both lung bases
C. Dry mucous membranes
D. Increased hematocrit
Correct Answer: B. Crackles heard in both lung bases
Rationale
Heart failure causes decreased cardiac output and fluid backs up into the pulmonary circulation,
leading to pulmonary edema.
• B is correct: Crackles indicate fluid accumulation in the alveoli.
• A: Flat neck veins suggest hypovolemia.
• C: Dry mucous membranes indicate dehydration.
• D: Elevated hematocrit is usually associated with fluid deficit.
Nursing Tip:
Always assess lung sounds, oxygen saturation, daily weights, and edema in clients with heart
failure.
Question 2
A nurse is assessing a client with chronic kidney disease. Which laboratory finding should the
nurse expect?
,A. Low serum creatinine
B. Elevated BUN
C. Low potassium
D. Increased calcium
Correct Answer: B. Elevated BUN
Rationale
Kidneys are unable to excrete nitrogenous wastes effectively.
Typical findings include:
• Elevated BUN
• Elevated creatinine
• Hyperkalemia
• Hyperphosphatemia
• Hypocalcemia
Question 3
A client suddenly develops unilateral weakness, facial droop, and slurred speech. What is the
nurse's priority action?
A. Obtain blood glucose
B. Encourage oral fluids
C. Place the client in Trendelenburg position
D. Administer aspirin immediately
Correct Answer: A. Obtain blood glucose
Rationale
Hypoglycemia can mimic stroke symptoms.
The nurse should rapidly assess blood glucose while activating the stroke protocol.
, • A is correct
• Aspirin should not be administered until hemorrhagic stroke has been ruled out.
Question 4
A client with COPD is receiving oxygen at 6 L/min via nasal cannula. Which assessment finding
requires immediate intervention?
A. Respiratory rate of 20/min
B. Oxygen saturation of 91%
C. Increasing drowsiness
D. Productive cough
Correct Answer: C. Increasing drowsiness
Rationale
High oxygen concentrations can suppress respiratory drive in some clients with COPD, leading
to carbon dioxide retention.
Signs include:
• Drowsiness
• Confusion
• Headache
• Decreased respiratory effort
Question 5
A nurse is caring for a client after thyroidectomy. Which assessment finding indicates possible
hypocalcemia?
A. Bradycardia
B. Positive Chvostek sign
C. Hypertension
, D. Hyperglycemia
Correct Answer: B. Positive Chvostek sign
Rationale
Accidental injury to the parathyroid glands may result in hypocalcemia.
Manifestations include:
• Chvostek sign
• Trousseau sign
• Muscle cramps
• Tetany
• Laryngeal stridor
Question 6
A client reports crushing substernal chest pain radiating to the left arm. Which medication should
the nurse anticipate administering first?
A. Morphine
B. Nitroglycerin
C. Atorvastatin
D. Metoprolol
Correct Answer: B. Nitroglycerin
Rationale
Nitroglycerin dilates coronary arteries and decreases myocardial oxygen demand.
Standard acute coronary syndrome treatment often follows the MONA concept (Morphine,
Oxygen as indicated, Nitroglycerin, Aspirin), with current practice tailoring oxygen to
hypoxemia.
The nurse should first assess blood pressure before administering nitroglycerin.
