VATI RN MED-SURG ASSESSMENT TEST – 300
QUESTIONS WITH ANSWERS (100% CORRECT
ANSWERS)
Complete A+ Guide for 2026
QUESTION 1
A nurse is caring for a client admitted with acute heart failure. Which assessment finding
requires immediate intervention?
A) Bilateral 2+ pitting edema in the ankles
B) Blood pressure of 150/90 mm Hg
C) Crackles throughout both lung fields and oxygen saturation of 84%
D) Weight gain of 2 lb (0.9 kg) over 24 hours
Answer: C) Crackles throughout both lung fields and oxygen saturation of 84%
Rationale: This client is experiencing severe pulmonary edema, resulting in impaired gas
exchange and hypoxemia. An oxygen saturation of 84% indicates inadequate oxygenation
requiring immediate intervention. Peripheral edema indicates fluid overload but is not
immediately life-threatening. Mild hypertension is common in heart failure and is less
urgent. Rapid weight gain signals worsening fluid retention but is not as immediately
dangerous as hypoxia. Use the ABCs (Airway, Breathing, Circulation) .
QUESTION 2
,A client with chronic kidney disease has the following laboratory results. Which result
should concern the nurse most?
A) Hemoglobin 10 g/dL
B) Potassium 6.4 mEq/L
C) BUN 48 mg/dL
D) Creatinine 3.2 mg/dL
Answer: B) Potassium 6.4 mEq/L
Rationale: Hyperkalemia can rapidly produce fatal cardiac dysrhythmias. Normal
potassium is 3.5–5.0 mEq/L. A potassium level of 6.4 mEq/L requires immediate
intervention. Mild anemia (hemoglobin 10) is expected with CKD. Elevated BUN and
creatinine reflect impaired kidney function but are not immediately life-threatening.
Priority nursing actions include placing the client on a cardiac monitor and notifying the
provider .
QUESTION 3
A client with COPD receives oxygen at 2 L/min via nasal cannula. Which assessment
finding indicates the oxygen therapy is effective?
A) Respiratory rate decreases from 34 to 22 breaths/min
B) Oxygen saturation increases from 86% to 91%
C) Client reports less dyspnea
D) All of the above
Answer: D) All of the above
Rationale: All findings indicate improved oxygenation. The expected oxygen saturation
goal for many COPD clients is 88%–92%. The nurse should also assess improved
,respiratory effort, reduced accessory muscle use, and improved comfort. Oxygen therapy is
effective when the client demonstrates clinical improvement in multiple parameters .
QUESTION 4
A client develops sudden chest pain and shortness of breath following hip replacement
surgery. Which complication should the nurse suspect first?
A) Atelectasis
B) Pulmonary embolism
C) Pneumonia
D) Heart failure
Answer: B) Pulmonary embolism
Rationale: Classic signs of pulmonary embolism include sudden dyspnea, sharp chest pain,
tachycardia, anxiety, and low oxygen saturation. Orthopedic surgery significantly increases
risk for venous thromboembolism. Immediate interventions include administering oxygen,
notifying the provider, and preparing for CT pulmonary angiography or anticoagulation as
prescribed .
QUESTION 5
A nurse is teaching a client prescribed warfarin. Which statement by the client indicates
understanding?
A) "I'll stop taking the medication when I feel better."
B) "I'll use an electric razor."
C) "I'll avoid all green vegetables."
D) "I'll take aspirin for headaches."
, Answer: B) "I'll use an electric razor."
Rationale: Warfarin increases bleeding risk. Safety precautions include using a soft
toothbrush, using an electric razor, avoiding injury, and reporting bleeding. Clients should
never stop anticoagulants without provider approval. Maintaining a consistent intake of
vitamin K is preferred over avoiding it completely. Aspirin increases bleeding risk unless
prescribed .
QUESTION 6
A client receiving packed red blood cells suddenly develops chills, fever, and flank pain.
What should the nurse do first?
A) Notify the provider
B) Slow the infusion
C) Stop the transfusion
D) Administer acetaminophen
Answer: C) Stop the transfusion
Rationale: These findings suggest an acute hemolytic transfusion reaction. Immediate
actions include stopping the transfusion, maintaining IV access with normal saline using
new tubing, notifying the provider and blood bank, monitoring vital signs, and obtaining
blood and urine specimens as ordered. Stopping the transfusion prevents further exposure
to incompatible blood .
QUESTION 7
A client with diabetes becomes confused and diaphoretic. Blood glucose = 52 mg/dL.
Which action should the nurse perform first?
QUESTIONS WITH ANSWERS (100% CORRECT
ANSWERS)
Complete A+ Guide for 2026
QUESTION 1
A nurse is caring for a client admitted with acute heart failure. Which assessment finding
requires immediate intervention?
A) Bilateral 2+ pitting edema in the ankles
B) Blood pressure of 150/90 mm Hg
C) Crackles throughout both lung fields and oxygen saturation of 84%
D) Weight gain of 2 lb (0.9 kg) over 24 hours
Answer: C) Crackles throughout both lung fields and oxygen saturation of 84%
Rationale: This client is experiencing severe pulmonary edema, resulting in impaired gas
exchange and hypoxemia. An oxygen saturation of 84% indicates inadequate oxygenation
requiring immediate intervention. Peripheral edema indicates fluid overload but is not
immediately life-threatening. Mild hypertension is common in heart failure and is less
urgent. Rapid weight gain signals worsening fluid retention but is not as immediately
dangerous as hypoxia. Use the ABCs (Airway, Breathing, Circulation) .
QUESTION 2
,A client with chronic kidney disease has the following laboratory results. Which result
should concern the nurse most?
A) Hemoglobin 10 g/dL
B) Potassium 6.4 mEq/L
C) BUN 48 mg/dL
D) Creatinine 3.2 mg/dL
Answer: B) Potassium 6.4 mEq/L
Rationale: Hyperkalemia can rapidly produce fatal cardiac dysrhythmias. Normal
potassium is 3.5–5.0 mEq/L. A potassium level of 6.4 mEq/L requires immediate
intervention. Mild anemia (hemoglobin 10) is expected with CKD. Elevated BUN and
creatinine reflect impaired kidney function but are not immediately life-threatening.
Priority nursing actions include placing the client on a cardiac monitor and notifying the
provider .
QUESTION 3
A client with COPD receives oxygen at 2 L/min via nasal cannula. Which assessment
finding indicates the oxygen therapy is effective?
A) Respiratory rate decreases from 34 to 22 breaths/min
B) Oxygen saturation increases from 86% to 91%
C) Client reports less dyspnea
D) All of the above
Answer: D) All of the above
Rationale: All findings indicate improved oxygenation. The expected oxygen saturation
goal for many COPD clients is 88%–92%. The nurse should also assess improved
,respiratory effort, reduced accessory muscle use, and improved comfort. Oxygen therapy is
effective when the client demonstrates clinical improvement in multiple parameters .
QUESTION 4
A client develops sudden chest pain and shortness of breath following hip replacement
surgery. Which complication should the nurse suspect first?
A) Atelectasis
B) Pulmonary embolism
C) Pneumonia
D) Heart failure
Answer: B) Pulmonary embolism
Rationale: Classic signs of pulmonary embolism include sudden dyspnea, sharp chest pain,
tachycardia, anxiety, and low oxygen saturation. Orthopedic surgery significantly increases
risk for venous thromboembolism. Immediate interventions include administering oxygen,
notifying the provider, and preparing for CT pulmonary angiography or anticoagulation as
prescribed .
QUESTION 5
A nurse is teaching a client prescribed warfarin. Which statement by the client indicates
understanding?
A) "I'll stop taking the medication when I feel better."
B) "I'll use an electric razor."
C) "I'll avoid all green vegetables."
D) "I'll take aspirin for headaches."
, Answer: B) "I'll use an electric razor."
Rationale: Warfarin increases bleeding risk. Safety precautions include using a soft
toothbrush, using an electric razor, avoiding injury, and reporting bleeding. Clients should
never stop anticoagulants without provider approval. Maintaining a consistent intake of
vitamin K is preferred over avoiding it completely. Aspirin increases bleeding risk unless
prescribed .
QUESTION 6
A client receiving packed red blood cells suddenly develops chills, fever, and flank pain.
What should the nurse do first?
A) Notify the provider
B) Slow the infusion
C) Stop the transfusion
D) Administer acetaminophen
Answer: C) Stop the transfusion
Rationale: These findings suggest an acute hemolytic transfusion reaction. Immediate
actions include stopping the transfusion, maintaining IV access with normal saline using
new tubing, notifying the provider and blood bank, monitoring vital signs, and obtaining
blood and urine specimens as ordered. Stopping the transfusion prevents further exposure
to incompatible blood .
QUESTION 7
A client with diabetes becomes confused and diaphoretic. Blood glucose = 52 mg/dL.
Which action should the nurse perform first?
