RN VATI ADULT MEDICAL SURGICAL
ASSESSMENT EXAM QUESTIONS AND CORRECT
ANSWERS WITH DETAILED RATIONALES
Cardiovascular (Questions 1–35)
1. A nurse is assessing a client who has left sided heart failure. Which of the
following findings should the nurse identify as a manifestation?
A. Dependent edema in the lower extremities
B. Frothy sputum
C. Jugular vein distention
D. Hepatomegaly
Correct Answer: B. Pink tinged frothy sputum indicates pulmonary edema, a
key manifestation of left sided heart failure due to increased pulmonary
venous pressure.
2. A nurse is caring for a client with heart failure and pulmonary edema.
Which of the following foods should the nurse instruct the client to avoid?
A. Fresh fruits
B. Lean meats
C. Cheese
D. Whole grains
,Correct Answer: C. Highsodium foods like cheese can worsen fluid retention in
clients with heart failure and pulmonary edema.
3. A nurse is assessing a client who has rightsided heart failure. Which of the
following findings should the nurse expect?
A. Crackles in the lungs
B. Peripheral edema
C. Orthopnea
D. Paroxysmal nocturnal dyspnea
Correct Answer: B. Rightsided heart failure leads to systemic venous
congestion, causing peripheral edema, jugular venous distention, and
hepatomegaly.
4. A client with hypertension is prescribed lisinopril. Which of the following
adverse effects should the nurse monitor?
A. Hyperkalemia
B. Bradycardia
C. Dry cough
D. Hypoglycemia
Correct Answer: C. Lisinopril, an ACE inhibitor, commonly causes a persistent
dry cough. Hyperkalemia is also possible, but cough is the classic side effect.
5. A nurse is preparing to administer digoxin to a client with heart failure.
Which of the following findings should prompt the nurse to withhold the
medication?
A. Heart rate 58/min
,B. Blood pressure 140/88 mmHg
C. Serum potassium 4.0 mEq/L
D. Respiratory rate 18/min
Correct Answer: A. Digoxin should be withheld if the apical pulse is below
60/min in an adult, as it can cause bradycardia and toxicity.
6. A client is 2 days postmyocardial infarction. Which of the following
complications should the nurse monitor for?
A. Cardiac tamponade
B. Pericarditis
C. Ventricular aneurysm
D. All of the above
Correct Answer: D. PostMI complications include pericarditis (Dressler's
syndrome), cardiac tamponade, and ventricular aneurysm.
7. A nurse is caring for a client with unstable angina. Which of the following
medications should the nurse anticipate administering?
A. Nitroglycerin sublingual
B. Warfarin orally
C. Digoxin IV
D. Furosemide IV
Correct Answer: A. Nitroglycerin sublingual is the firstline treatment for acute
angina to reduce preload and afterload.
, 8. A client is prescribed clopidogrel after a stent placement. Which of the
following statements by the client indicates understanding?
A. "I can stop this medication when I feel better."
B. "I will take this with my morning coffee."
C. "I need to report any unusual bleeding."
D. "I can take ibuprofen for headaches."
Correct Answer: C. Clopidogrel is an antiplatelet; clients should report
bleeding. It should not be stopped without provider approval.
9. A nurse is assessing a client for possible deep vein thrombosis (DVT). Which
of the following findings is most indicative?
A. Bilateral calf tenderness
B. Unilateral leg swelling and pain
C. Positive Homans' sign
D. Fever and chills
Correct Answer: B. Unilateral swelling, pain, and warmth are key signs of DVT.
Homans' sign is unreliable and no longer recommended.
10. A client on heparin therapy has an aPTT of 110 seconds. Which of the
following actions should the nurse take?
A. Continue the infusion
B. Decrease the infusion rate
C. Administer protamine sulfate
D. Notify the provider
ASSESSMENT EXAM QUESTIONS AND CORRECT
ANSWERS WITH DETAILED RATIONALES
Cardiovascular (Questions 1–35)
1. A nurse is assessing a client who has left sided heart failure. Which of the
following findings should the nurse identify as a manifestation?
A. Dependent edema in the lower extremities
B. Frothy sputum
C. Jugular vein distention
D. Hepatomegaly
Correct Answer: B. Pink tinged frothy sputum indicates pulmonary edema, a
key manifestation of left sided heart failure due to increased pulmonary
venous pressure.
2. A nurse is caring for a client with heart failure and pulmonary edema.
Which of the following foods should the nurse instruct the client to avoid?
A. Fresh fruits
B. Lean meats
C. Cheese
D. Whole grains
,Correct Answer: C. Highsodium foods like cheese can worsen fluid retention in
clients with heart failure and pulmonary edema.
3. A nurse is assessing a client who has rightsided heart failure. Which of the
following findings should the nurse expect?
A. Crackles in the lungs
B. Peripheral edema
C. Orthopnea
D. Paroxysmal nocturnal dyspnea
Correct Answer: B. Rightsided heart failure leads to systemic venous
congestion, causing peripheral edema, jugular venous distention, and
hepatomegaly.
4. A client with hypertension is prescribed lisinopril. Which of the following
adverse effects should the nurse monitor?
A. Hyperkalemia
B. Bradycardia
C. Dry cough
D. Hypoglycemia
Correct Answer: C. Lisinopril, an ACE inhibitor, commonly causes a persistent
dry cough. Hyperkalemia is also possible, but cough is the classic side effect.
5. A nurse is preparing to administer digoxin to a client with heart failure.
Which of the following findings should prompt the nurse to withhold the
medication?
A. Heart rate 58/min
,B. Blood pressure 140/88 mmHg
C. Serum potassium 4.0 mEq/L
D. Respiratory rate 18/min
Correct Answer: A. Digoxin should be withheld if the apical pulse is below
60/min in an adult, as it can cause bradycardia and toxicity.
6. A client is 2 days postmyocardial infarction. Which of the following
complications should the nurse monitor for?
A. Cardiac tamponade
B. Pericarditis
C. Ventricular aneurysm
D. All of the above
Correct Answer: D. PostMI complications include pericarditis (Dressler's
syndrome), cardiac tamponade, and ventricular aneurysm.
7. A nurse is caring for a client with unstable angina. Which of the following
medications should the nurse anticipate administering?
A. Nitroglycerin sublingual
B. Warfarin orally
C. Digoxin IV
D. Furosemide IV
Correct Answer: A. Nitroglycerin sublingual is the firstline treatment for acute
angina to reduce preload and afterload.
, 8. A client is prescribed clopidogrel after a stent placement. Which of the
following statements by the client indicates understanding?
A. "I can stop this medication when I feel better."
B. "I will take this with my morning coffee."
C. "I need to report any unusual bleeding."
D. "I can take ibuprofen for headaches."
Correct Answer: C. Clopidogrel is an antiplatelet; clients should report
bleeding. It should not be stopped without provider approval.
9. A nurse is assessing a client for possible deep vein thrombosis (DVT). Which
of the following findings is most indicative?
A. Bilateral calf tenderness
B. Unilateral leg swelling and pain
C. Positive Homans' sign
D. Fever and chills
Correct Answer: B. Unilateral swelling, pain, and warmth are key signs of DVT.
Homans' sign is unreliable and no longer recommended.
10. A client on heparin therapy has an aPTT of 110 seconds. Which of the
following actions should the nurse take?
A. Continue the infusion
B. Decrease the infusion rate
C. Administer protamine sulfate
D. Notify the provider
