RN VATI Adult Medical Surgical Assessment Exam
Questions with Correct Verified Answers (Latest) –
Guaranteed Pass | Complete Med-Surg Nursing
1. A nurse is caring for a client who is 12 hours postoperative following an open
cholecystectomy. The client has a T-tube in place. Which of the following findings should the
nurse report to the provider immediately?
A. 200 mL of bile-colored drainage in the T-tube collection bag over 24 hours.
B. The client reports nausea and has vomited once.
C. The T-tube has stopped draining and the client reports severe right upper quadrant pain.
D. The client's temperature is 37.8° C (100.0° F).
Correct Answer: C
Rationale: A sudden cessation of T-tube drainage accompanied by severe pain can indicate a
blockage or dislodgement of the tube, leading to bile peritonitis, a life-threatening complication.
This requires immediate intervention. Options A, B, and D are expected or non-urgent findings
that should be monitored but do not require immediate notification of the provider.
2. A client is scheduled for surgery and the nurse is reviewing the pre-operative checklist.
Which of the following actions is the priority?
A. Ensure the client has signed the informed consent.
B. Verify the client's NPO status.
C. Administer the prescribed pre-operative antibiotic.
D. Confirm the client's identity and surgical site with the surgical team.
Correct Answer: B
Rationale: The priority action is to verify the client's NPO status. Aspiration during
anesthesia is a life-threatening risk. While verifying identity, site, and consent are all critical,
ensuring the client has not eaten or drunk anything is the most immediate safety check to
prevent a catastrophic event. Administering antibiotics is important but can be done after this
crucial safety verification.
3. A nurse is assessing a client who is 24 hours postoperative from a total hip arthroplasty.
Which of the following findings is the highest priority to report?
A. A small amount of serosanguineous drainage on the dressing.
B. The client reports a pain level of 4 on a 0-10 scale.
C. The client's affected leg is swollen, warm, and tender to the touch.
D. The client is unable to ambulate without assistance.
, Correct Answer: C
Rationale: Unilateral leg swelling, warmth, and tenderness are classic signs of a deep vein
thrombosis (DVT). A DVT can dislodge and become a pulmonary embolism (PE), which is life-
threatening. This finding must be reported immediately. Options A, B, and D are expected
findings in the immediate postoperative period.
4. A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the
following findings should the nurse expect?
A. Hyperactive deep tendon reflexes.
B. Muscle weakness and fatigue.
C. Peaked T waves on the ECG.
D. Increased bowel sounds.
Correct Answer: B
Rationale: A potassium level of 3.1 mEq/L indicates hypokalemia. Manifestations of
hypokalemia include muscle weakness, fatigue, decreased deep tendon reflexes, and decreased
bowel sounds. Peaked T waves are a manifestation of hyperkalemia.
5. A nurse is preparing to administer IV potassium chloride to a client with severe
hypokalemia. Which of the following actions is essential?
A. Administer the medication as an IV push.
B. Ensure adequate urine output before administration.
C. Add the medication to a bag of 0.9% sodium chloride for a rapid infusion.
D. Monitor the client for signs of hyperkalemia.
Correct Answer: B
Rationale: Potassium is excreted by the kidneys. Administering potassium to a client with
inadequate renal output can lead to life-threatening hyperkalemia. Therefore, ensuring
adequate urine output is essential. IV potassium must never be given as a push and should be
infused via a pump at a controlled rate, typically no faster than 10-20 mEq/hour.
6. A client is admitted with dehydration and a serum sodium level of 155 mEq/L. The nurse
should anticipate which of the following prescriptions?
A. Fluid restriction.
B. Administration of hypotonic IV fluids (e.g., 0.45% sodium chloride).
C. Administration of hypertonic IV fluids (e.g., 3% sodium chloride).
D. Administration of a diuretic.
Correct Answer: B
Rationale: A serum sodium level of 155 mEq/L indicates hypernatremia, often caused by
,dehydration. Treatment involves replacing fluids with a hypotonic solution, such as 0.45%
sodium chloride, to move water back into the cells and dilute the serum sodium. Fluid
restriction and diuretics would worsen the condition.
7. A nurse is teaching a client about the signs of an incisional infection. Which of the following
statements by the client indicates a need for further teaching?
A. "I should expect some clear drainage for the first few days."
B. "A fever of 101 degrees is something I should report."
C. "It's normal for the area around my incision to become more red and swollen over time."
D. "I will call my doctor if the incision starts to open up."
Correct Answer: C
Rationale: Increasing redness, swelling, warmth, and pain at the incision site are classic
signs of infection, not a normal part of healing. This statement indicates a need for further
teaching. A low-grade fever can occur, but a fever over 100.4°F (38°C) should be reported.
8. A nurse is assessing a client who had a tonsillectomy 4 hours ago. Which of the following
findings indicates a potential complication?
A. The client is swallowing frequently.
B. The client's voice is hoarse.
C. The client reports a pain level of 5/10.
D. The client is drooling blood-tinged saliva.
Correct Answer: A
Rationale: Frequent swallowing is a classic sign of bleeding in the throat following a
tonsillectomy, as the client is trying to clear the trickle of blood. This is a sign of hemorrhage
and is a priority finding. Hoarseness and pain are expected.
9. A client with a history of heart failure is at risk for fluid overload. Which of the following
early signs should the nurse monitor for?
A. Decreased blood pressure.
B. Bounding pulses and neck vein distention.
C. Dry mucous membranes.
D. Decreased urine output.
Correct Answer: B
Rationale: Early signs of fluid overload include a full, bounding pulse, distended neck veins,
and increased blood pressure. Weight gain is also an early sign. Decreased urine output and dry
mucous membranes are signs of dehydration. Decreased blood pressure is a later sign of fluid
overload (due to pump failure).
, 10. A nurse is caring for a client receiving a blood transfusion. Ten minutes into the
transfusion, the client reports chills, flank pain, and has a fever. What is the priority action?
A. Stop the transfusion immediately.
B. Slow the transfusion and reassess the client in 15 minutes.
C. Administer the prescribed antipyretic.
D. Notify the blood bank.
Correct Answer: A
Rationale: These findings indicate an acute hemolytic transfusion reaction, a life-
threatening emergency. The priority action is to immediately stop the transfusion. Then, the
nurse should maintain IV access with new tubing and 0.9% sodium chloride, notify the provider
and blood bank, and monitor the client.
11. A nurse is reviewing the lab results for a client scheduled for surgery. Which of the
following values should the nurse report to the provider?
A. WBC 8,000/mm³
B. Hemoglobin 10.1 g/dL
C. Platelets 150,000/mm³
D. INR 2.5 (client is not on anticoagulants)
Correct Answer: D
Rationale: An INR of 2.5 is elevated, indicating a significant risk for bleeding. This is a critical
finding that must be reported before surgery. The other values are within or near normal limits.
12. A client is postoperative day 1 following a colon resection. The nurse notes the client has a
nasogastric (NG) tube to low intermittent suction. Which of the following is an expected
outcome of this intervention?
A. Decreased nausea and vomiting.
B. Increased bowel sounds.
C. Relief of constipation.
D. Correction of an electrolyte imbalance.
Correct Answer: A
Rationale: An NG tube to suction is used to decompress the stomach and remove gastric
contents, which decreases nausea and vomiting. It does not increase bowel sounds or relieve
constipation. It can actually cause an electrolyte imbalance due to the loss of gastric fluids.
13. A nurse is caring for a client who is 6 hours postoperative and has not voided. Which of
the following actions should the nurse take first?
A. Insert a straight catheter.
Questions with Correct Verified Answers (Latest) –
Guaranteed Pass | Complete Med-Surg Nursing
1. A nurse is caring for a client who is 12 hours postoperative following an open
cholecystectomy. The client has a T-tube in place. Which of the following findings should the
nurse report to the provider immediately?
A. 200 mL of bile-colored drainage in the T-tube collection bag over 24 hours.
B. The client reports nausea and has vomited once.
C. The T-tube has stopped draining and the client reports severe right upper quadrant pain.
D. The client's temperature is 37.8° C (100.0° F).
Correct Answer: C
Rationale: A sudden cessation of T-tube drainage accompanied by severe pain can indicate a
blockage or dislodgement of the tube, leading to bile peritonitis, a life-threatening complication.
This requires immediate intervention. Options A, B, and D are expected or non-urgent findings
that should be monitored but do not require immediate notification of the provider.
2. A client is scheduled for surgery and the nurse is reviewing the pre-operative checklist.
Which of the following actions is the priority?
A. Ensure the client has signed the informed consent.
B. Verify the client's NPO status.
C. Administer the prescribed pre-operative antibiotic.
D. Confirm the client's identity and surgical site with the surgical team.
Correct Answer: B
Rationale: The priority action is to verify the client's NPO status. Aspiration during
anesthesia is a life-threatening risk. While verifying identity, site, and consent are all critical,
ensuring the client has not eaten or drunk anything is the most immediate safety check to
prevent a catastrophic event. Administering antibiotics is important but can be done after this
crucial safety verification.
3. A nurse is assessing a client who is 24 hours postoperative from a total hip arthroplasty.
Which of the following findings is the highest priority to report?
A. A small amount of serosanguineous drainage on the dressing.
B. The client reports a pain level of 4 on a 0-10 scale.
C. The client's affected leg is swollen, warm, and tender to the touch.
D. The client is unable to ambulate without assistance.
, Correct Answer: C
Rationale: Unilateral leg swelling, warmth, and tenderness are classic signs of a deep vein
thrombosis (DVT). A DVT can dislodge and become a pulmonary embolism (PE), which is life-
threatening. This finding must be reported immediately. Options A, B, and D are expected
findings in the immediate postoperative period.
4. A nurse is caring for a client who has a serum potassium level of 3.1 mEq/L. Which of the
following findings should the nurse expect?
A. Hyperactive deep tendon reflexes.
B. Muscle weakness and fatigue.
C. Peaked T waves on the ECG.
D. Increased bowel sounds.
Correct Answer: B
Rationale: A potassium level of 3.1 mEq/L indicates hypokalemia. Manifestations of
hypokalemia include muscle weakness, fatigue, decreased deep tendon reflexes, and decreased
bowel sounds. Peaked T waves are a manifestation of hyperkalemia.
5. A nurse is preparing to administer IV potassium chloride to a client with severe
hypokalemia. Which of the following actions is essential?
A. Administer the medication as an IV push.
B. Ensure adequate urine output before administration.
C. Add the medication to a bag of 0.9% sodium chloride for a rapid infusion.
D. Monitor the client for signs of hyperkalemia.
Correct Answer: B
Rationale: Potassium is excreted by the kidneys. Administering potassium to a client with
inadequate renal output can lead to life-threatening hyperkalemia. Therefore, ensuring
adequate urine output is essential. IV potassium must never be given as a push and should be
infused via a pump at a controlled rate, typically no faster than 10-20 mEq/hour.
6. A client is admitted with dehydration and a serum sodium level of 155 mEq/L. The nurse
should anticipate which of the following prescriptions?
A. Fluid restriction.
B. Administration of hypotonic IV fluids (e.g., 0.45% sodium chloride).
C. Administration of hypertonic IV fluids (e.g., 3% sodium chloride).
D. Administration of a diuretic.
Correct Answer: B
Rationale: A serum sodium level of 155 mEq/L indicates hypernatremia, often caused by
,dehydration. Treatment involves replacing fluids with a hypotonic solution, such as 0.45%
sodium chloride, to move water back into the cells and dilute the serum sodium. Fluid
restriction and diuretics would worsen the condition.
7. A nurse is teaching a client about the signs of an incisional infection. Which of the following
statements by the client indicates a need for further teaching?
A. "I should expect some clear drainage for the first few days."
B. "A fever of 101 degrees is something I should report."
C. "It's normal for the area around my incision to become more red and swollen over time."
D. "I will call my doctor if the incision starts to open up."
Correct Answer: C
Rationale: Increasing redness, swelling, warmth, and pain at the incision site are classic
signs of infection, not a normal part of healing. This statement indicates a need for further
teaching. A low-grade fever can occur, but a fever over 100.4°F (38°C) should be reported.
8. A nurse is assessing a client who had a tonsillectomy 4 hours ago. Which of the following
findings indicates a potential complication?
A. The client is swallowing frequently.
B. The client's voice is hoarse.
C. The client reports a pain level of 5/10.
D. The client is drooling blood-tinged saliva.
Correct Answer: A
Rationale: Frequent swallowing is a classic sign of bleeding in the throat following a
tonsillectomy, as the client is trying to clear the trickle of blood. This is a sign of hemorrhage
and is a priority finding. Hoarseness and pain are expected.
9. A client with a history of heart failure is at risk for fluid overload. Which of the following
early signs should the nurse monitor for?
A. Decreased blood pressure.
B. Bounding pulses and neck vein distention.
C. Dry mucous membranes.
D. Decreased urine output.
Correct Answer: B
Rationale: Early signs of fluid overload include a full, bounding pulse, distended neck veins,
and increased blood pressure. Weight gain is also an early sign. Decreased urine output and dry
mucous membranes are signs of dehydration. Decreased blood pressure is a later sign of fluid
overload (due to pump failure).
, 10. A nurse is caring for a client receiving a blood transfusion. Ten minutes into the
transfusion, the client reports chills, flank pain, and has a fever. What is the priority action?
A. Stop the transfusion immediately.
B. Slow the transfusion and reassess the client in 15 minutes.
C. Administer the prescribed antipyretic.
D. Notify the blood bank.
Correct Answer: A
Rationale: These findings indicate an acute hemolytic transfusion reaction, a life-
threatening emergency. The priority action is to immediately stop the transfusion. Then, the
nurse should maintain IV access with new tubing and 0.9% sodium chloride, notify the provider
and blood bank, and monitor the client.
11. A nurse is reviewing the lab results for a client scheduled for surgery. Which of the
following values should the nurse report to the provider?
A. WBC 8,000/mm³
B. Hemoglobin 10.1 g/dL
C. Platelets 150,000/mm³
D. INR 2.5 (client is not on anticoagulants)
Correct Answer: D
Rationale: An INR of 2.5 is elevated, indicating a significant risk for bleeding. This is a critical
finding that must be reported before surgery. The other values are within or near normal limits.
12. A client is postoperative day 1 following a colon resection. The nurse notes the client has a
nasogastric (NG) tube to low intermittent suction. Which of the following is an expected
outcome of this intervention?
A. Decreased nausea and vomiting.
B. Increased bowel sounds.
C. Relief of constipation.
D. Correction of an electrolyte imbalance.
Correct Answer: A
Rationale: An NG tube to suction is used to decompress the stomach and remove gastric
contents, which decreases nausea and vomiting. It does not increase bowel sounds or relieve
constipation. It can actually cause an electrolyte imbalance due to the loss of gastric fluids.
13. A nurse is caring for a client who is 6 hours postoperative and has not voided. Which of
the following actions should the nurse take first?
A. Insert a straight catheter.
