VATI Med-Surg pre-assessment Exam
Questions & Answers (Grade A+)
A nurse is preparing to administer a transfusion of RBCs to a client
who has heart failure. For which of the following manifestations
should the nurse monitor to prevent fluid volume overload? (Select
all that apply.)
A. Dyspnea
B. Gastrointestinal bloating
C. Jugular vein distention
D. Confusion
E. Hypotension -
correct answer ✅A. Dyspnea
C. Jugular vein distention
D. Confusion
Dyspnea is a clinical manifestation of fluid volume overload. Jugular
vein distention is a clinical manifestation of fluid volume overload.
Confusion is a clinical manifestation of fluid volume overload.
A nurse is caring for a client who has a spinal cord injury and
suspects the client is developing autonomic dysreflexia. Which of
the following actions should the nurse take first?
,VATI Med-Surg pre-assessment Exam
Questions & Answers (Grade A+)
A. Check the client for a fecal impaction.
B. Examine the client for areas of skin breakdown.
C. Check the client's bladder for distention.
D. Place the client in a sitting position. -
correct answer ✅D. Place the client in a sitting position.
The nurse should use the least invasive intervention first. Therefore,
the nurse should place the client in a sitting position to decrease
the manifestation of hypertension.
The nurse might have to check the client for fecal impaction, which
can precipitate autonomic dysreflexia. However, the nurse should
use a less invasive intervention first. The nurse might have to
examine the client's skin for areas of skin breakdown or pressure,
which can trigger autonomic dysreflexia. However, the nurse should
use a less invasive intervention first. The nurse might have to check
the client for bladder distention, which can precipitate autonomic
dysreflexia. However, the nurse should use a less invasive
intervention first.
,VATI Med-Surg pre-assessment Exam
Questions & Answers (Grade A+)
A nurse is teaching a newly licensed nurse about the risk factors for
dehiscence for clients who have surgical incisions. Which of the
following factors should the nurse include in the teaching? (Select
all that apply.)
A. Poor nutritional state
B. Altered mental status
C. Obesity
D. Pain medication administration
E. Wound infection -
correct answer ✅A. Poor nutritional state
C. Obesity
E. Wound infection
A nurse is caring for a client who has an endotracheal tube and is
receiving mechanical ventilation. Which of the following
interventions should the nurse take to reduce the risk for ventilator-
associated pneumonia?
A. Position the head of the client's bed in the flat position.
B. Turn the client every 4 hr.
, VATI Med-Surg pre-assessment Exam
Questions & Answers (Grade A+)
C. Rinse the client's mouth with an antimicrobial solution every 4
hr.
D. Perform hand hygiene prior to suctioning the client's
endotracheal tube. -
correct answer ✅C. Rinse the client's mouth with an antimicrobial
solution every 4 hr.
The nurse should brush the client's teeth every 8 hr and rinse the
client's mouth with an antimicrobial rinse every 2 hr to reduce the
growth of bacteria.
The nurse should elevate the head of the client's bed 30° to reduce
the risk for aspiration and pneumonia. The nurse should turn the
client every 2 hr to promote lung expansion and reduce the risk for
pneumonia. The nurse should perform hand hygiene prior to
suctioning the client's endotracheal tube to reduce the risk of
introducing bacteria.
A nurse is providing instruction to a new nurse about caring for
clients who are receiving diuretic therapy to treat heart failure. The
nurse should explain that which of the following medications puts
clients at risk for both hyperkalemia and hyponatremia?
Questions & Answers (Grade A+)
A nurse is preparing to administer a transfusion of RBCs to a client
who has heart failure. For which of the following manifestations
should the nurse monitor to prevent fluid volume overload? (Select
all that apply.)
A. Dyspnea
B. Gastrointestinal bloating
C. Jugular vein distention
D. Confusion
E. Hypotension -
correct answer ✅A. Dyspnea
C. Jugular vein distention
D. Confusion
Dyspnea is a clinical manifestation of fluid volume overload. Jugular
vein distention is a clinical manifestation of fluid volume overload.
Confusion is a clinical manifestation of fluid volume overload.
A nurse is caring for a client who has a spinal cord injury and
suspects the client is developing autonomic dysreflexia. Which of
the following actions should the nurse take first?
,VATI Med-Surg pre-assessment Exam
Questions & Answers (Grade A+)
A. Check the client for a fecal impaction.
B. Examine the client for areas of skin breakdown.
C. Check the client's bladder for distention.
D. Place the client in a sitting position. -
correct answer ✅D. Place the client in a sitting position.
The nurse should use the least invasive intervention first. Therefore,
the nurse should place the client in a sitting position to decrease
the manifestation of hypertension.
The nurse might have to check the client for fecal impaction, which
can precipitate autonomic dysreflexia. However, the nurse should
use a less invasive intervention first. The nurse might have to
examine the client's skin for areas of skin breakdown or pressure,
which can trigger autonomic dysreflexia. However, the nurse should
use a less invasive intervention first. The nurse might have to check
the client for bladder distention, which can precipitate autonomic
dysreflexia. However, the nurse should use a less invasive
intervention first.
,VATI Med-Surg pre-assessment Exam
Questions & Answers (Grade A+)
A nurse is teaching a newly licensed nurse about the risk factors for
dehiscence for clients who have surgical incisions. Which of the
following factors should the nurse include in the teaching? (Select
all that apply.)
A. Poor nutritional state
B. Altered mental status
C. Obesity
D. Pain medication administration
E. Wound infection -
correct answer ✅A. Poor nutritional state
C. Obesity
E. Wound infection
A nurse is caring for a client who has an endotracheal tube and is
receiving mechanical ventilation. Which of the following
interventions should the nurse take to reduce the risk for ventilator-
associated pneumonia?
A. Position the head of the client's bed in the flat position.
B. Turn the client every 4 hr.
, VATI Med-Surg pre-assessment Exam
Questions & Answers (Grade A+)
C. Rinse the client's mouth with an antimicrobial solution every 4
hr.
D. Perform hand hygiene prior to suctioning the client's
endotracheal tube. -
correct answer ✅C. Rinse the client's mouth with an antimicrobial
solution every 4 hr.
The nurse should brush the client's teeth every 8 hr and rinse the
client's mouth with an antimicrobial rinse every 2 hr to reduce the
growth of bacteria.
The nurse should elevate the head of the client's bed 30° to reduce
the risk for aspiration and pneumonia. The nurse should turn the
client every 2 hr to promote lung expansion and reduce the risk for
pneumonia. The nurse should perform hand hygiene prior to
suctioning the client's endotracheal tube to reduce the risk of
introducing bacteria.
A nurse is providing instruction to a new nurse about caring for
clients who are receiving diuretic therapy to treat heart failure. The
nurse should explain that which of the following medications puts
clients at risk for both hyperkalemia and hyponatremia?
