MEDSURG VATI ASSESSMENT
90 Q'S AND 100% VERIFIED
ANSWERS (LATEST UPDATE)
A nurse is assis*ng 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 pericardi*s and temp. 38 c 100.4
- a client who has chest tubes and an oxygen sat of 90%
using the airway, breathing, and circula*on approach to client care, the nurse
should determine that the priority finding is the client's oxygen satura*on level,
which is below the expected reference range of 95% to 100%. Therefore, the
nurse should aMend to this client first.
A nurse is collec*ng data from a client who was admiMed 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
,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 evalua*on
of a client's level of consciousness. The test is divided into three sec*ons 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 suc*on. For which
of the following findings should the nurse no*fy the charge nurse
- flucta*on of the water level in the water seal chamber
-constant bubling in the suc*on control chamber
- periodic bubbling in the water seal chamber
- persistent bubbling in the water seal chamber
- 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 no*fy 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 instruc*ons should the nurse include
in the teaching
-comb your hair with the unaffected arm
-dress your unaffected side first
, choose clothing with buMons
-shave with your affected side
Comb your hair with the unaffected arm
the nurse should instruct the client to brush their hair with the unaffected arm
to reduce frustra*on and increase independence and self-esteem.
A nurse is collec*ng data from a client and auscultates intermiMent high-
pitched sounds during inspira*on over the lower base of the lungs. The nurse
should iden*fy this finding as which of the following lungs sounds
- fine crackles
-stridor
-rhonchi
-fric*on
- fine crackles
fine crackles are auscultated in the base of the lungs as air moves through
airway secre*ons. Fine crackles are intermiMent, high-pitched sounds heard
more oXen during inspira*on.
A nurse is collec*ng data from a client who has coronary artery disease. Which
of the following
manifesta*ons should the nurse iden*fy as an indica*on that the client has
angina ( sata)
- chest discomfort radiated
- pain las*ng less that 15mins
- pain that is relieved with rest
90 Q'S AND 100% VERIFIED
ANSWERS (LATEST UPDATE)
A nurse is assis*ng 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 pericardi*s and temp. 38 c 100.4
- a client who has chest tubes and an oxygen sat of 90%
using the airway, breathing, and circula*on approach to client care, the nurse
should determine that the priority finding is the client's oxygen satura*on level,
which is below the expected reference range of 95% to 100%. Therefore, the
nurse should aMend to this client first.
A nurse is collec*ng data from a client who was admiMed 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
,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 evalua*on
of a client's level of consciousness. The test is divided into three sec*ons 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 suc*on. For which
of the following findings should the nurse no*fy the charge nurse
- flucta*on of the water level in the water seal chamber
-constant bubling in the suc*on control chamber
- periodic bubbling in the water seal chamber
- persistent bubbling in the water seal chamber
- 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 no*fy 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 instruc*ons should the nurse include
in the teaching
-comb your hair with the unaffected arm
-dress your unaffected side first
, choose clothing with buMons
-shave with your affected side
Comb your hair with the unaffected arm
the nurse should instruct the client to brush their hair with the unaffected arm
to reduce frustra*on and increase independence and self-esteem.
A nurse is collec*ng data from a client and auscultates intermiMent high-
pitched sounds during inspira*on over the lower base of the lungs. The nurse
should iden*fy this finding as which of the following lungs sounds
- fine crackles
-stridor
-rhonchi
-fric*on
- fine crackles
fine crackles are auscultated in the base of the lungs as air moves through
airway secre*ons. Fine crackles are intermiMent, high-pitched sounds heard
more oXen during inspira*on.
A nurse is collec*ng data from a client who has coronary artery disease. Which
of the following
manifesta*ons should the nurse iden*fy as an indica*on that the client has
angina ( sata)
- chest discomfort radiated
- pain las*ng less that 15mins
- pain that is relieved with rest
