Med Surg vATI QUESTIONS WITH CORRECT
ANSWERS.
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 - correct 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 - correct 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
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber - correct 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 - correct 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 - correct 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 - correct answer - Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with res
A nurse is receiving change-of-shift report for a group of clients. Which of the
following clients
should the nurse plan to see first?
- A client who has diabetes mellitus with diaphoretic - correct answer A client
who has diabetes mellitus with diaphoretic
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority action is to attend to a client who has diabetes mellitus
ANSWERS.
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 - correct 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 - correct 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
-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber - correct 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 - correct 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 - correct 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 - correct answer - Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with res
A nurse is receiving change-of-shift report for a group of clients. Which of the
following clients
should the nurse plan to see first?
- A client who has diabetes mellitus with diaphoretic - correct answer A client
who has diabetes mellitus with diaphoretic
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority action is to attend to a client who has diabetes mellitus
