• RN VATI Adult
Medical Surgical 09/14/2026
EXAM
RN VATI Adult Medical Surgical Assessment
Exam QUESTIONS AND ANSWERS ALREADY
GRADED A+. 100% Verified Solutions | Updated
Per Latest Guidelines | Graded A+
The nurse in the emergency room assesses a client with a head trauma and notes a Glasgow Coma Scale (GCS)
score of 5. What actions will the nurse take to ensure the client's safety? (Select all that apply.)
A.
Place the client in the supine position.
B.
Assess airway and suction secretions as needed.
C.
Change the client's position every 2 hours.
P 1
, • RN VATI Adult
Medical Surgical 09/14/2026
EXAM
D.
Avoid mouth care, to avoid stimulating a seizure.
E.
Monitor for drainage from the ears. - Correct Answer :B, C, E
Rationale:The client should be at least sitting at a 45 degree angle to avoid aspiration and increased intracranial
pressure. Provide frequent mouth care as the client is unable to do so at this time. The remaining actions are
appropriate for the client with a GCS score of 5.
A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are the priority nursing
actions for this client? (Select all that apply.)
A.
Assess lung sounds.
B.
Look for equal and bilateral expansion of the chest.
C.
Monitor skin color.
D.
Evaluate the need for suctioning.
E.
Tell the family the client is expected to fully recover.
F.
Make sure the ventilator alarms are set. - Correct Answer :A, B, C, D, F
Rationale:The outcome of the client is too early to relay to the family. The nurse must not offer false
reassurance. The remaining actions are correct for a client on a ventilator.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion
for hemothorax. What is the best initial action for the nurse to take?
A.
P 2
, • RN VATI Adult
Medical Surgical 09/14/2026
EXAM
Document this expected decrease in drainage.
B.
Clamp the chest tube while assessing for air leaks.
C.
Milk the tube to remove any excessive blood clot buildup.
D.
Assess for kinks or dependent loops in the tubing. - Correct Answer :D
Rationale:The least invasive nursing action should be performed first to determine why the drainage has
diminished. Option A is completed after assessing for any problems causing the decrease in drainage. Option B is
no longer considered standard protocol because the increase in pressure may be harmful to the client. Option C
is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.
A client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if dialysis will
always be needed. Which pathophysiologic consequence should the nurse explain that supports the need for
temporary dialysis until acute tubular necrosis subsides?
A.
Azotemia
B.
Oliguria
C.
Hyperkalemia
D.
Nephron obstruction - Correct Answer :D
Rationale:CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by
hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure,
which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The
obstruction of urine flow will resolve with the return of an adequate glomerular filtration rate, and when it does,
dialysis will no longer be needed. Options A, B, and C are manifestations seen in the acute and chronic forms of
kidney disease.
P 3
, • RN VATI Adult
Medical Surgical 09/14/2026
EXAM
The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding
warrants immediate action by the nurse?
A.
A unilateral pupil that is dilated and nonreactive to light
B.
Client cries out when awakened by a verbal stimulus.
C.
Client demonstrates a loss of memory of the events leading up to the injury.
D.
Onset of nausea, headache, and vertigo - Correct Answer :A
Rationale:Any change in pupil size and reactivity is an indication of increasing intracranial pressure and should be
reported to the health care provider immediately. Option B is a normal response to being awakened. Options C
and D are common manifestations of head injury and are of less immediacy than option A.
A 62-year-old client who lives alone tripped on a scatter rug resulting in a fractured hip. Which predisposing
factor most likely contributed to the fracture in the proximal end of her femur?
A.
Failing eyesight resulting in an unsafe environment
B.
Renal osteodystrophy resulting from chronic kidney disease (CKD)
C.
Osteoporosis resulting from declining hormone levels
D.
Cerebral vessel changes causing transient ischemic attacks - Correct Answer :C
Rationale:The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced
calcium in the bones as a result of hormonal changes in the perimenopausal years. Option A may or may not
have contributed to the accident, but eye changes were not involved in promoting the hip fracture. Option B is
not a common condition of older people but is associated with CKD. Although option D may result in transient
ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis.
P 4
Medical Surgical 09/14/2026
EXAM
RN VATI Adult Medical Surgical Assessment
Exam QUESTIONS AND ANSWERS ALREADY
GRADED A+. 100% Verified Solutions | Updated
Per Latest Guidelines | Graded A+
The nurse in the emergency room assesses a client with a head trauma and notes a Glasgow Coma Scale (GCS)
score of 5. What actions will the nurse take to ensure the client's safety? (Select all that apply.)
A.
Place the client in the supine position.
B.
Assess airway and suction secretions as needed.
C.
Change the client's position every 2 hours.
P 1
, • RN VATI Adult
Medical Surgical 09/14/2026
EXAM
D.
Avoid mouth care, to avoid stimulating a seizure.
E.
Monitor for drainage from the ears. - Correct Answer :B, C, E
Rationale:The client should be at least sitting at a 45 degree angle to avoid aspiration and increased intracranial
pressure. Provide frequent mouth care as the client is unable to do so at this time. The remaining actions are
appropriate for the client with a GCS score of 5.
A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are the priority nursing
actions for this client? (Select all that apply.)
A.
Assess lung sounds.
B.
Look for equal and bilateral expansion of the chest.
C.
Monitor skin color.
D.
Evaluate the need for suctioning.
E.
Tell the family the client is expected to fully recover.
F.
Make sure the ventilator alarms are set. - Correct Answer :A, B, C, D, F
Rationale:The outcome of the client is too early to relay to the family. The nurse must not offer false
reassurance. The remaining actions are correct for a client on a ventilator.
The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion
for hemothorax. What is the best initial action for the nurse to take?
A.
P 2
, • RN VATI Adult
Medical Surgical 09/14/2026
EXAM
Document this expected decrease in drainage.
B.
Clamp the chest tube while assessing for air leaks.
C.
Milk the tube to remove any excessive blood clot buildup.
D.
Assess for kinks or dependent loops in the tubing. - Correct Answer :D
Rationale:The least invasive nursing action should be performed first to determine why the drainage has
diminished. Option A is completed after assessing for any problems causing the decrease in drainage. Option B is
no longer considered standard protocol because the increase in pressure may be harmful to the client. Option C
is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.
A client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if dialysis will
always be needed. Which pathophysiologic consequence should the nurse explain that supports the need for
temporary dialysis until acute tubular necrosis subsides?
A.
Azotemia
B.
Oliguria
C.
Hyperkalemia
D.
Nephron obstruction - Correct Answer :D
Rationale:CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by
hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure,
which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The
obstruction of urine flow will resolve with the return of an adequate glomerular filtration rate, and when it does,
dialysis will no longer be needed. Options A, B, and C are manifestations seen in the acute and chronic forms of
kidney disease.
P 3
, • RN VATI Adult
Medical Surgical 09/14/2026
EXAM
The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding
warrants immediate action by the nurse?
A.
A unilateral pupil that is dilated and nonreactive to light
B.
Client cries out when awakened by a verbal stimulus.
C.
Client demonstrates a loss of memory of the events leading up to the injury.
D.
Onset of nausea, headache, and vertigo - Correct Answer :A
Rationale:Any change in pupil size and reactivity is an indication of increasing intracranial pressure and should be
reported to the health care provider immediately. Option B is a normal response to being awakened. Options C
and D are common manifestations of head injury and are of less immediacy than option A.
A 62-year-old client who lives alone tripped on a scatter rug resulting in a fractured hip. Which predisposing
factor most likely contributed to the fracture in the proximal end of her femur?
A.
Failing eyesight resulting in an unsafe environment
B.
Renal osteodystrophy resulting from chronic kidney disease (CKD)
C.
Osteoporosis resulting from declining hormone levels
D.
Cerebral vessel changes causing transient ischemic attacks - Correct Answer :C
Rationale:The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced
calcium in the bones as a result of hormonal changes in the perimenopausal years. Option A may or may not
have contributed to the accident, but eye changes were not involved in promoting the hip fracture. Option B is
not a common condition of older people but is associated with CKD. Although option D may result in transient
ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis.
P 4
