RN VATI Adult Medical Surgical 2019(Score
100%) Download to score A
Section 1: Perioperative & Surgical Nursing (Q1–12)
1. A nurse is assessing a client 6 hours after an open cholecystectomy. Which finding requires
immediate intervention?
A. Serosanguineous drainage on the dressing
B. Respiratory rate 28/min with shallow breathing and restlessness
C. Pain rated 5/10 at the incision
D. Absent bowel sounds
Rationale: Tachypnea with shallow breathing, restlessness, and anxiety after abdominal
surgery are early signs of hypoxemia/atelectasis or pulmonary embolism and require immediate
assessment. Serosanguineous drainage, moderate pain, and absent bowel sounds are expected
findings in the immediate postoperative period.
2. Which actions should the nurse include in the plan of care to prevent postoperative
atelectasis? (SATA)
A. Incentive spirometry every 1–2 hours while awake
B. Splinting the incision during coughing and deep breathing
C. Early ambulation
D. Administering opioids around the clock without regard to sedation
E. Repositioning every 2 hours
Rationale: Lung expansion techniques, splinting, early mobility, and repositioning prevent
atelectasis. Oversedation from opioids suppresses cough and respiratory effort, increasing
atelectasis risk — opioids should be titrated to effect.
3. A client scheduled for surgery reports taking warfarin. Which action should the nurse take
first?
A. Document the medication
B. Notify the provider and obtain coagulation studies
C. Hold the client's morning insulin
D. Teach the client about vitamin K
, Rationale: Warfarin increases bleeding risk; the provider must be notified and INR/PT
evaluated before surgery. Documentation is important but not the priority action. Insulin and
vitamin K are unrelated to this immediate safety issue.
4. A nurse is providing preoperative teaching for a client who will have a total hip
arthroplasty. Which instruction is priority?
A. "You will be on bed rest for 3 days."
B. "You will use an abduction pillow or wedge between your legs."
C. "You may cross your legs when sitting."
D. "Avoid ankle pumps to prevent dislodgement."
Rationale: Maintaining abduction prevents hip prosthesis dislocation. Early mobility, not
bed rest, is encouraged. Crossing legs causes adduction and dislocation risk. Ankle pumps
prevent DVT and are encouraged.
5. A postoperative client has a drain with 150 mL of bright red drainage in the first hour.
Which action should the nurse take?
A. Clamp the drain
B. Notify the surgeon immediately and monitor vital signs
C. Document as a normal finding
D. Irrigate the drain
Rationale: Sudden bright red drainage >100 mL/hr suggests hemorrhage. Notify the
surgeon and assess for hypovolemic shock. Clamping or irrigating without an order is unsafe.
6. Which client is at greatest risk for malignant hyperthermia during surgery?
A. A client with a history of asthma
B. A client with a family history of malignant hyperthermia receiving succinylcholine and
inhaled anesthetics
C. A client taking beta blockers
D. A client with diabetes
Rationale: Malignant hyperthermia is a genetic disorder triggered by depolarizing muscle
relaxants (succinylcholine) and volatile anesthetics. Family history is the key risk factor.
7. A nurse is caring for a client in the PACU. Which finding indicates the client is ready for
discharge from Phase I?
A. Alert and oriented, stable vital signs, protective reflexes intact
B. Pain rated 8/10
C. Temperature 38.3°C (101°F)
D. Urine output 10 mL/hr
, Rationale: PACU Phase I discharge criteria include stable vitals, alertness, and return of
protective reflexes. Uncontrolled pain, fever, and oliguria require further evaluation.
8. A client is 1 day postoperative following a colon resection. Which finding should the nurse
report to the provider?
A. Temperature 37.6°C (99.7°F)
B. Heart rate 124/min with blood pressure 88/54 mm Hg
C. Incisional pain 4/10
D. Dry mucous membranes
Rationale: Tachycardia and hypotension suggest hypovolemia/hemorrhage or sepsis. This
requires immediate reporting. Low-grade fever and mild pain are common postoperatively.
9. Which interventions prevent venous thromboembolism after major surgery? (SATA)
A. Sequential compression devices
B. Early ambulation
C. Subcutaneous heparin as prescribed
D. Leg exercises/ankle pumps
E. Massaging the calves vigorously
Rationale: SCDs, ambulation, anticoagulants, and ankle pumps prevent DVT. Vigorous calf
massage can dislodge a thrombus and is contraindicated.
10. A nurse is teaching a client who will undergo cataract surgery with local anesthesia. Which
statement indicates understanding?
A. "I will need to lie flat for 6 hours."
B. "I should avoid bending and straining after surgery."
C. "I can rub my eye if it itches."
D. "I should stop all eye drops before surgery."
Rationale: Avoiding bending/straining prevents increased intraocular pressure. Rubbing the
eye is contraindicated. Prescribed eye drops are usually continued.
11. A client is scheduled for an MRI. Which client requires further screening before the
procedure?
A. A client with a knee replacement made of titanium
B. A client with a pacemaker
C. A client with claustrophobia
D. A client with hearing aids
, Rationale: Pacemakers may be affected by the magnetic field and are a contraindication
unless MRI-conditional. Titanium implants are generally safe. Claustrophobia and hearing aids
are managed with sedation and removal.
12. A nurse is assessing a client's surgical incision on postoperative day 5. Which finding
indicates infection?
A. Serous drainage
B. Warmth, redness, and purulent drainage
C. Incisional pain
D. Staples intact
Rationale: Warmth, erythema, and purulent drainage indicate infection. Serous drainage
and pain are expected.
Section 2: Fluid, Electrolyte & Acid-Base Balance (Q13–24)
13. A client has a potassium level of 6.2 mEq/L. Which action is priority?
A. Administer potassium chloride
B. Place the client on continuous cardiac monitoring
C. Encourage a high-potassium diet
D. Administer furosemide IV push
Rationale: Hyperkalemia can cause lethal dysrhythmias; cardiac monitoring is priority.
Potassium should never be given. Furosemide may be used but requires an order and
monitoring.
14. Which client is at highest risk for hypokalemia?
A. A client with renal failure
B. A client taking furosemide with prolonged vomiting
C. A client taking potassium-sparing diuretics
D. A client with Addison's disease
Rationale: Loop diuretics and GI losses deplete potassium. Renal failure, potassium-sparing
diuretics, and Addison's disease cause hyperkalemia.
15. A nurse is assessing a client with fluid volume deficit. Which findings are expected? (SATA)
A. Tachycardia
B. Decreased urine output
C. Dry mucous membranes
100%) Download to score A
Section 1: Perioperative & Surgical Nursing (Q1–12)
1. A nurse is assessing a client 6 hours after an open cholecystectomy. Which finding requires
immediate intervention?
A. Serosanguineous drainage on the dressing
B. Respiratory rate 28/min with shallow breathing and restlessness
C. Pain rated 5/10 at the incision
D. Absent bowel sounds
Rationale: Tachypnea with shallow breathing, restlessness, and anxiety after abdominal
surgery are early signs of hypoxemia/atelectasis or pulmonary embolism and require immediate
assessment. Serosanguineous drainage, moderate pain, and absent bowel sounds are expected
findings in the immediate postoperative period.
2. Which actions should the nurse include in the plan of care to prevent postoperative
atelectasis? (SATA)
A. Incentive spirometry every 1–2 hours while awake
B. Splinting the incision during coughing and deep breathing
C. Early ambulation
D. Administering opioids around the clock without regard to sedation
E. Repositioning every 2 hours
Rationale: Lung expansion techniques, splinting, early mobility, and repositioning prevent
atelectasis. Oversedation from opioids suppresses cough and respiratory effort, increasing
atelectasis risk — opioids should be titrated to effect.
3. A client scheduled for surgery reports taking warfarin. Which action should the nurse take
first?
A. Document the medication
B. Notify the provider and obtain coagulation studies
C. Hold the client's morning insulin
D. Teach the client about vitamin K
, Rationale: Warfarin increases bleeding risk; the provider must be notified and INR/PT
evaluated before surgery. Documentation is important but not the priority action. Insulin and
vitamin K are unrelated to this immediate safety issue.
4. A nurse is providing preoperative teaching for a client who will have a total hip
arthroplasty. Which instruction is priority?
A. "You will be on bed rest for 3 days."
B. "You will use an abduction pillow or wedge between your legs."
C. "You may cross your legs when sitting."
D. "Avoid ankle pumps to prevent dislodgement."
Rationale: Maintaining abduction prevents hip prosthesis dislocation. Early mobility, not
bed rest, is encouraged. Crossing legs causes adduction and dislocation risk. Ankle pumps
prevent DVT and are encouraged.
5. A postoperative client has a drain with 150 mL of bright red drainage in the first hour.
Which action should the nurse take?
A. Clamp the drain
B. Notify the surgeon immediately and monitor vital signs
C. Document as a normal finding
D. Irrigate the drain
Rationale: Sudden bright red drainage >100 mL/hr suggests hemorrhage. Notify the
surgeon and assess for hypovolemic shock. Clamping or irrigating without an order is unsafe.
6. Which client is at greatest risk for malignant hyperthermia during surgery?
A. A client with a history of asthma
B. A client with a family history of malignant hyperthermia receiving succinylcholine and
inhaled anesthetics
C. A client taking beta blockers
D. A client with diabetes
Rationale: Malignant hyperthermia is a genetic disorder triggered by depolarizing muscle
relaxants (succinylcholine) and volatile anesthetics. Family history is the key risk factor.
7. A nurse is caring for a client in the PACU. Which finding indicates the client is ready for
discharge from Phase I?
A. Alert and oriented, stable vital signs, protective reflexes intact
B. Pain rated 8/10
C. Temperature 38.3°C (101°F)
D. Urine output 10 mL/hr
, Rationale: PACU Phase I discharge criteria include stable vitals, alertness, and return of
protective reflexes. Uncontrolled pain, fever, and oliguria require further evaluation.
8. A client is 1 day postoperative following a colon resection. Which finding should the nurse
report to the provider?
A. Temperature 37.6°C (99.7°F)
B. Heart rate 124/min with blood pressure 88/54 mm Hg
C. Incisional pain 4/10
D. Dry mucous membranes
Rationale: Tachycardia and hypotension suggest hypovolemia/hemorrhage or sepsis. This
requires immediate reporting. Low-grade fever and mild pain are common postoperatively.
9. Which interventions prevent venous thromboembolism after major surgery? (SATA)
A. Sequential compression devices
B. Early ambulation
C. Subcutaneous heparin as prescribed
D. Leg exercises/ankle pumps
E. Massaging the calves vigorously
Rationale: SCDs, ambulation, anticoagulants, and ankle pumps prevent DVT. Vigorous calf
massage can dislodge a thrombus and is contraindicated.
10. A nurse is teaching a client who will undergo cataract surgery with local anesthesia. Which
statement indicates understanding?
A. "I will need to lie flat for 6 hours."
B. "I should avoid bending and straining after surgery."
C. "I can rub my eye if it itches."
D. "I should stop all eye drops before surgery."
Rationale: Avoiding bending/straining prevents increased intraocular pressure. Rubbing the
eye is contraindicated. Prescribed eye drops are usually continued.
11. A client is scheduled for an MRI. Which client requires further screening before the
procedure?
A. A client with a knee replacement made of titanium
B. A client with a pacemaker
C. A client with claustrophobia
D. A client with hearing aids
, Rationale: Pacemakers may be affected by the magnetic field and are a contraindication
unless MRI-conditional. Titanium implants are generally safe. Claustrophobia and hearing aids
are managed with sedation and removal.
12. A nurse is assessing a client's surgical incision on postoperative day 5. Which finding
indicates infection?
A. Serous drainage
B. Warmth, redness, and purulent drainage
C. Incisional pain
D. Staples intact
Rationale: Warmth, erythema, and purulent drainage indicate infection. Serous drainage
and pain are expected.
Section 2: Fluid, Electrolyte & Acid-Base Balance (Q13–24)
13. A client has a potassium level of 6.2 mEq/L. Which action is priority?
A. Administer potassium chloride
B. Place the client on continuous cardiac monitoring
C. Encourage a high-potassium diet
D. Administer furosemide IV push
Rationale: Hyperkalemia can cause lethal dysrhythmias; cardiac monitoring is priority.
Potassium should never be given. Furosemide may be used but requires an order and
monitoring.
14. Which client is at highest risk for hypokalemia?
A. A client with renal failure
B. A client taking furosemide with prolonged vomiting
C. A client taking potassium-sparing diuretics
D. A client with Addison's disease
Rationale: Loop diuretics and GI losses deplete potassium. Renal failure, potassium-sparing
diuretics, and Addison's disease cause hyperkalemia.
15. A nurse is assessing a client with fluid volume deficit. Which findings are expected? (SATA)
A. Tachycardia
B. Decreased urine output
C. Dry mucous membranes
