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MEDSURG VATI ASSESSMENT EXAM LATEST UPDATE
2024\2025 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES | GRADED A+
A nurse examining a client's rhythm strips notices no visible P waves but many
small, erratic
spikes throughout the strip as well as variable ventricular rate. The nurse should
identify and
report this pattern as which of the following dysrhythmias?
- Atrial Fibrillation - Answer: - Atrial Fibrillation
The nurse should identify that during atrial fibrillation, the atrioventricular node
cannot respond to so many atrial impulses. Therefore, it sends impulses to the
ventricles in an erratic way, which accounts for these characteristics on the client's
rhythm strip.
A nurse is administering a tap water enema to a client who has constipation. The
client reports
abdominal cramping during instillation of the enema. Which of the following
actions should the
nurse take
- Slow the rate of fluid flow - Answer: - Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the intestinal
spasm to pass if cramping occurs during administration of the enema. Lowering the
height of the enema bag will decrease the rate the fluid enters the bowel. Tap water
enemas consist of 500 mL to 1 L of fluid that is instilled into the bowel to soften
feces. The volume of fluid stimulates peristalsis.
A nurse is contributing to the plan for a client who has dysphagia following a
stroke. Which of the following actions should the nurse include in the plan of care
to prevent aspiration? - Answer: - Keep the client upright for 30 mins after a meal.
The nurse should keep the client upright for 30 to 60 min after a meal to reduce the
risk for aspiration.
A nurse is reinforcing teaching about mammograms with an adult who is
postmenopausal. Which of the following statements indicate to the nurse that the
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client understand the teaching? - Answer: - I should have mammogram every 1 to
2 years
The nurse should remind the client that the American Cancer Society recommends
clients continue to have a mammogram every 1 to 2 years as they age and are in
good health.
A nurse is assisting with the care of four clients. Which of the following clients is
the priority for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 130 over 4hrs
- A client who has a permanent pacemaker with heart rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4 - Answer: - A client who has
chest tubes and an oxygen Sat of 90%
Using the airway, breathing, and circulation approach to client care, the nurse
should determine that the priority finding is the client's oxygen saturation level,
which is below the expected reference range of 95% to 100%. Therefore, the nurse
should attend to this client first.
A nurse is collecting data from a client who was admitted with a Glasgow Coma
Scale of 3. Which
of the following findings should the nurse expect?
- Vacalizes sound
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands - Answer: Nonresponsive Commands
A client who has a GCS of less than 8 has evidence of severe head injury and is in
a comatose state. The GCS is a standardized tool that allows for the evaluation of a
client's level of consciousness. The test is divided into three sections that evaluate
eye opening, motor response, and verbal response. The GCS ranges from a high
score of 15 (fully alert) to a low score of 3 (fully comatose).
A nurse is monitoring a client who has a pneumothorax and a chest tube in place
with a closed chest drainage system connected to low suction. For which of the
following findings should the nurse notify the charge nurse
- Fluctation of the water level in the water seal chamber
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-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber - Answer: - Persistent bubbling in
the water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates an air leak in
the drainage system. The nurse should notify the charge nurse of this finding.
A nurse is reinforcing teaching with a male client who has right sided hemiparesis
about
preforming ADL's. Which of the following instructions should the nurse include in
the teaching
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side - Answer: Comb your hair with the unaffected arm
The nurse should instruct the client to brush their hair with the unaffected arm to
reduce frustration and increase independence and self-esteem.
A nurse is collecting data from a client and auscultates intermittent high-pitched
sounds during inspiration over the lower base of the lungs. The nurse should
identify this finding as which of the following lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction - Answer: - Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves through airway
secretions. Fine crackles are intermittent, high-pitched sounds heard more often
during inspiration.
A nurse is collecting data from a client who has coronary artery disease. Which of
the following
manifestations should the nurse identify as an indication that the client has angina (
SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with rest - Answer: - Chest Discomfort Radiated
MEDSURG VATI ASSESSMENT EXAM LATEST UPDATE
2024\2025 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES | GRADED A+
A nurse examining a client's rhythm strips notices no visible P waves but many
small, erratic
spikes throughout the strip as well as variable ventricular rate. The nurse should
identify and
report this pattern as which of the following dysrhythmias?
- Atrial Fibrillation - Answer: - Atrial Fibrillation
The nurse should identify that during atrial fibrillation, the atrioventricular node
cannot respond to so many atrial impulses. Therefore, it sends impulses to the
ventricles in an erratic way, which accounts for these characteristics on the client's
rhythm strip.
A nurse is administering a tap water enema to a client who has constipation. The
client reports
abdominal cramping during instillation of the enema. Which of the following
actions should the
nurse take
- Slow the rate of fluid flow - Answer: - Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the intestinal
spasm to pass if cramping occurs during administration of the enema. Lowering the
height of the enema bag will decrease the rate the fluid enters the bowel. Tap water
enemas consist of 500 mL to 1 L of fluid that is instilled into the bowel to soften
feces. The volume of fluid stimulates peristalsis.
A nurse is contributing to the plan for a client who has dysphagia following a
stroke. Which of the following actions should the nurse include in the plan of care
to prevent aspiration? - Answer: - Keep the client upright for 30 mins after a meal.
The nurse should keep the client upright for 30 to 60 min after a meal to reduce the
risk for aspiration.
A nurse is reinforcing teaching about mammograms with an adult who is
postmenopausal. Which of the following statements indicate to the nurse that the
,Page 2 of 20
client understand the teaching? - Answer: - I should have mammogram every 1 to
2 years
The nurse should remind the client that the American Cancer Society recommends
clients continue to have a mammogram every 1 to 2 years as they age and are in
good health.
A nurse is assisting with the care of four clients. Which of the following clients is
the priority for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 130 over 4hrs
- A client who has a permanent pacemaker with heart rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4 - Answer: - A client who has
chest tubes and an oxygen Sat of 90%
Using the airway, breathing, and circulation approach to client care, the nurse
should determine that the priority finding is the client's oxygen saturation level,
which is below the expected reference range of 95% to 100%. Therefore, the nurse
should attend to this client first.
A nurse is collecting data from a client who was admitted with a Glasgow Coma
Scale of 3. Which
of the following findings should the nurse expect?
- Vacalizes sound
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands - Answer: Nonresponsive Commands
A client who has a GCS of less than 8 has evidence of severe head injury and is in
a comatose state. The GCS is a standardized tool that allows for the evaluation of a
client's level of consciousness. The test is divided into three sections that evaluate
eye opening, motor response, and verbal response. The GCS ranges from a high
score of 15 (fully alert) to a low score of 3 (fully comatose).
A nurse is monitoring a client who has a pneumothorax and a chest tube in place
with a closed chest drainage system connected to low suction. For which of the
following findings should the nurse notify the charge nurse
- Fluctation of the water level in the water seal chamber
, Page 3 of 20
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber - Answer: - Persistent bubbling in
the water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates an air leak in
the drainage system. The nurse should notify the charge nurse of this finding.
A nurse is reinforcing teaching with a male client who has right sided hemiparesis
about
preforming ADL's. Which of the following instructions should the nurse include in
the teaching
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side - Answer: Comb your hair with the unaffected arm
The nurse should instruct the client to brush their hair with the unaffected arm to
reduce frustration and increase independence and self-esteem.
A nurse is collecting data from a client and auscultates intermittent high-pitched
sounds during inspiration over the lower base of the lungs. The nurse should
identify this finding as which of the following lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction - Answer: - Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves through airway
secretions. Fine crackles are intermittent, high-pitched sounds heard more often
during inspiration.
A nurse is collecting data from a client who has coronary artery disease. Which of
the following
manifestations should the nurse identify as an indication that the client has angina (
SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with rest - Answer: - Chest Discomfort Radiated
