RN VATI Adult Medical-Surgical
Assessment
Questions and Answers with Rationales| Latest Update|
Guaranteed Pass
Covering:
Cardiovascular • Respiratory • Renal/Genitourinary • Gastrointestinal
Endocrine • Neurological • Musculoskeletal • Hematologic/Oncologic
Immune/Infectious Disease • Perioperative Care • Fluid & Electrolyte Balance
Shock & Emergency Care
Page 1 of 101
, 1.Cardiovascular
Question 1 (Cardiovascular)
A nurse is caring for a client who reports substernal chest pain radiating to the
left arm. The client is diaphoretic and anxious. Which action should the nurse
take first?
A. Obtain a 12-lead ECG ✔
B. Administer sublingual nitroglycerin
C. Notify the provider
D. Start a peripheral IV line
Correct Answer: A
Rationale: An ECG should be obtained within 10 minutes of the onset of chest
pain because it is the fastest way to identify ST-segment changes indicating
myocardial ischemia or infarction, which directs all subsequent treatment
decisions. While nitroglycerin, provider notification, and IV access are all
appropriate near-simultaneous actions in an evolving MI protocol, the ECG takes
priority because time-sensitive diagnostic data ("time is muscle") must be
obtained immediately to guide reperfusion therapy. Nitroglycerin (B) should not
be the very first action because hypotension must be ruled out first and the ECG
informs whether the presentation is STEMI versus NSTEMI. Notifying the
provider (C) and starting an IV (D) are important but follow rapid ECG
acquisition in the standard chest pain protocol.
Page 2 of 101
,Question 2 (Cardiovascular)
A client with heart failure is prescribed furosemide 40 mg IV push. Which
assessment finding requires the nurse to hold the medication and notify the
provider?
A. Potassium level of 3.0 mEq/L ✔
B. Blood pressure of 128/76 mmHg
C. Weight loss of 1 lb since yesterday
D. Urine output of 40 mL/hr
Correct Answer: A
Rationale: Furosemide is a loop diuretic that causes potassium wasting, and a
serum potassium of 3.0 mEq/L is below the normal range of 3.5-5.0 mEq/L;
administering another dose could worsen hypokalemia and precipitate life-
threatening dysrhythmias. The provider should be notified so potassium can be
repleted before or along with the diuretic. A blood pressure of 128/76 mmHg (B)
is within normal limits and not a contraindication. A 1-lb weight loss (C) reflects
appropriate diuresis and expected therapeutic response. Urine output of 40 mL/
hr (D) is within the normal minimum of 30 mL/hr and does not indicate a need
to hold the medication.
Page 3 of 101
, Question 3 (Cardiovascular)
The nurse is teaching a client newly diagnosed with hypertension about lifestyle
modifications. Which statement by the client indicates a need for further
teaching?
A. "I will limit my sodium intake to less than 2,300 mg per day."
B. "I can continue drinking three cups of coffee each morning." ✔
C. "I should aim for at least 150 minutes of moderate exercise weekly."
D. "I will try to lose weight if I am overweight."
Correct Answer: B
Rationale: Caffeine is a stimulant that can transiently raise blood pressure and
heart rate, so clients with hypertension are generally advised to limit caffeine
intake rather than continue high daily consumption; this statement indicates a
need for further teaching. Limiting sodium to less than 2,300 mg daily (A) is
consistent with DASH diet recommendations for blood pressure control.
Engaging in at least 150 minutes of moderate exercise weekly (C) is an
evidence-based recommendation that lowers blood pressure. Weight loss in
overweight clients (D) is a first-line, non-pharmacologic strategy proven to
reduce blood pressure, so this statement is correct and does not require
correction.
Page 4 of 101
Assessment
Questions and Answers with Rationales| Latest Update|
Guaranteed Pass
Covering:
Cardiovascular • Respiratory • Renal/Genitourinary • Gastrointestinal
Endocrine • Neurological • Musculoskeletal • Hematologic/Oncologic
Immune/Infectious Disease • Perioperative Care • Fluid & Electrolyte Balance
Shock & Emergency Care
Page 1 of 101
, 1.Cardiovascular
Question 1 (Cardiovascular)
A nurse is caring for a client who reports substernal chest pain radiating to the
left arm. The client is diaphoretic and anxious. Which action should the nurse
take first?
A. Obtain a 12-lead ECG ✔
B. Administer sublingual nitroglycerin
C. Notify the provider
D. Start a peripheral IV line
Correct Answer: A
Rationale: An ECG should be obtained within 10 minutes of the onset of chest
pain because it is the fastest way to identify ST-segment changes indicating
myocardial ischemia or infarction, which directs all subsequent treatment
decisions. While nitroglycerin, provider notification, and IV access are all
appropriate near-simultaneous actions in an evolving MI protocol, the ECG takes
priority because time-sensitive diagnostic data ("time is muscle") must be
obtained immediately to guide reperfusion therapy. Nitroglycerin (B) should not
be the very first action because hypotension must be ruled out first and the ECG
informs whether the presentation is STEMI versus NSTEMI. Notifying the
provider (C) and starting an IV (D) are important but follow rapid ECG
acquisition in the standard chest pain protocol.
Page 2 of 101
,Question 2 (Cardiovascular)
A client with heart failure is prescribed furosemide 40 mg IV push. Which
assessment finding requires the nurse to hold the medication and notify the
provider?
A. Potassium level of 3.0 mEq/L ✔
B. Blood pressure of 128/76 mmHg
C. Weight loss of 1 lb since yesterday
D. Urine output of 40 mL/hr
Correct Answer: A
Rationale: Furosemide is a loop diuretic that causes potassium wasting, and a
serum potassium of 3.0 mEq/L is below the normal range of 3.5-5.0 mEq/L;
administering another dose could worsen hypokalemia and precipitate life-
threatening dysrhythmias. The provider should be notified so potassium can be
repleted before or along with the diuretic. A blood pressure of 128/76 mmHg (B)
is within normal limits and not a contraindication. A 1-lb weight loss (C) reflects
appropriate diuresis and expected therapeutic response. Urine output of 40 mL/
hr (D) is within the normal minimum of 30 mL/hr and does not indicate a need
to hold the medication.
Page 3 of 101
, Question 3 (Cardiovascular)
The nurse is teaching a client newly diagnosed with hypertension about lifestyle
modifications. Which statement by the client indicates a need for further
teaching?
A. "I will limit my sodium intake to less than 2,300 mg per day."
B. "I can continue drinking three cups of coffee each morning." ✔
C. "I should aim for at least 150 minutes of moderate exercise weekly."
D. "I will try to lose weight if I am overweight."
Correct Answer: B
Rationale: Caffeine is a stimulant that can transiently raise blood pressure and
heart rate, so clients with hypertension are generally advised to limit caffeine
intake rather than continue high daily consumption; this statement indicates a
need for further teaching. Limiting sodium to less than 2,300 mg daily (A) is
consistent with DASH diet recommendations for blood pressure control.
Engaging in at least 150 minutes of moderate exercise weekly (C) is an
evidence-based recommendation that lowers blood pressure. Weight loss in
overweight clients (D) is a first-line, non-pharmacologic strategy proven to
reduce blood pressure, so this statement is correct and does not require
correction.
Page 4 of 101
