VATI Med Surg
A home health nurse is assisting a client with planning care for a family member who has
Alzheimer's disease. Which of the following instructions should the nurse include? - ANS
-Remove clutter from rooms and hallways
- This allows the client is able to walk without the risk of falling or tripping over objects. Later in
the disease, the client can experience seizures, so cluttered areas could be a risk to the client
\A home health nurse is inspecting a client's residence for electrical hazards as part of the
agency's quality improvement plan. Which of the following findings should the nurse identify as
a safety hazard? - ANS -AN IV PUMP IS PLUGGED INTO AN OUTLET NEAR THE SINK.
- The nurse should plug all electrical appliances into outlets away from wet areas. Water
conducts electricity and places the client at risk for electrocution.
\A nurse in a long-term care facility is caring for a client who has dementia. Which of the
following actions should the nurse take? - ANS -PROVIDE FINGER FOOD AT MEALTIME.
- The nurse should provide the client who has dementia with fingers foods. Clients who have
dementia can have difficulty sitting still and tend to wander, which makes weight loss and
malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal.
\A nurse in an emergency department is assessing a client who is overusing prescribed
diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should
the nurse expect? - ANS -LOW URINE SPECFIC GRAVITY.
-A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity.
The increased excretion of water alters the ratio of particulate matter, which affects the specific
gravity.
\A nurse in an emergency department is caring for a client who is confused, has a temperature
of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke. Which of the
following actions should the nurse take first? - ANS -ADMINISTER OXYGEN USING A
HIGH-CONCENTRATION MASK.
- The first action the nurse should take when using the airway, breathing, and circulation
approach to client care is to ensure that the client has a patent airway and administer oxygen
using a high-concentration mask to promote oxygen perfusion to vital organs.
\A nurse is analyzing the ABG results of a client who is in RESPIRATORY ACIDOSIS. Which of
the following mechanisms should the nurse identify as responsible for this acid-base
imbalance? - ANS -RETENTION OF CARBON DIOXIDE.
- Retention of carbon dioxide can result from respiratory depression, inadequate chest
expansion, airway obstruction, or decreased alveolar capillary diffusion.
,\A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse
should identify which of the following findings as an indication the client is at risk for fluid volume
deficit? - ANS -SURGICAL DRAIN OUTPUT 300 ML DURING AN 8 HOUR SHIFT.
- A client who had lumbar spinal surgery should not have more than 250 mL from a drain in the
first 24 hr. Therefore, 300 mL in 8 hr can indicate that the client is at risk for fluid volume deficit.
\A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV)
fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the
IV tubing and needleless connector device are disconnected. Which of the following actions
should the nurse take first? - ANS -CLOSE THE PINCH CLAMP ON THE CVC.
- The greatest risk to this client is air embolism resulting from accidental disconnection of the
CVC tubing. Therefore, the priority action is to clamp the catheter immediately by closing the
pinch clamp to prevent any further air from entering the system. When an air embolism occurs,
air enters through the central vein into the right ventricle and lodges by the pulmonary valve,
decreasing the amount of blood that is able to enter into the ventricle and the pulmonary
arteries.
\A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage
system. Which of the following findings should the nurse report to the provider? - ANS
-CONSTANT BUBBLING IN THE WATER SEAL CHAMBER.
- Constant bubbling in the water seal chamber can be an indication of an air leak, which is
caused by a disruption in the system such as a loose connection. Pulmonary air leaks create
intermittent bubbling that is synchronous with respiration. This finding should be reported to the
provider immediately.
\A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should
identify which of the following findings as an indication of a microvascular complication? - ANS
-RETINOPATHY.
- Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting from
pathologic changes in small blood vessels, which eventually cause tissue damage, cell death in
the retina, and blindness.
\A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should
identify that which of the following findings is a manifestation of hyperglycemia? - ANS
-INCREASED THIRST.
- The nurse should teach the client that increased thirst, or polydipsia, is a manifestation of
hyperglycemia, which can lead to dehydration. Other manifestations of hyperglycemia include
an increase in appetite, or polyphagia, an increase in urine production, or polyuria, and fatigue.
\A nurse is assessing a client who has a new diagnosis of PERICARDITIS. Which of the
following findings should the nurse identify as a manifestation of cardiac tamponade? - ANS
-PARADOXICAL PULSE.
, - Cardiac tamponade results from an excess of fluid in the pericardial cavity and causes a
sudden drop in cardiac output. Paradoxical pulse is a systolic blood pressure of 10 mm Hg or
more on expiration and is a manifestation of cardiac tamponade. The nurse should report
manifestations of cardiac tamponade to the provider immediately.
\A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the
following quadrants should the nurse anticipate the client to be experiencing abdominal pain? -
ANS -LEFT LOWER QUADRANT.
- Diverticula commonly develop in the sigmoid colon because of the high pressure it takes to
move stool into the rectum. Therefore, the pain with this disorder is often in the left lower
quadrant.
\A nurse is assessing a client who has Cushing's syndrome. Which of the following findings
should the nurse expect? - ANS -Osteoporosis
Bone become thinner as a result of mineral loss & nitrogen depletion.
\A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse identify as a manifestation of left-sided heart failure? - ANS -Frothy sputum
Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be
life-threatening. Therefore, the nurse should notify the provider immediately.
\A nurse is assessing a client who has RIGHT-SIDED HEART FAILURE. Which of the following
findings should the nurse identify as a manifestation of RIGHT- SIDED HEART FAILURE? -
ANS -INCREASED ABDOMINAL GIRTH
\A nurse is assessing a client who has suspected APPENDICITIS. Which of the following
manifestations should the nurse expect? - ANS -- Elevated WBC count (20,000+)
A client who has acute appendicitis will show a moderate elevation of the WBC count from
10,000 to 18,000/mm3. If the WBC count is greater than 20,000/mm3, it can indicate a
perforated appendix.
- Rebound tenderness (RLQ)
A client who has appendicitis develops localized pain over the right lower quadrant of the
abdomen. When the area is palpated, pain occurs during release of pressure on the client's
abdomen.
- Anorexia
A client who has acute appendicitis experiences nausea, vomiting, and reduced appetite.
\A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of
the following findings is an indication to the nurse that the client is experiencing an adverse
effect of the therapy? - ANS -SKIN CHANGES.
A client who is receiving radiation therapy to the breast will have localized adverse effects of the
treatment, such as skin changes, esophagitis, and lymphedema.
\A nurse is assessing a client who recently had a myocardial infarction. Which of the following
findings indicates that the client might be developing PULMONARY EDEMA? - ANS -- Pink,
frothy sputum
- Tachypnea
A home health nurse is assisting a client with planning care for a family member who has
Alzheimer's disease. Which of the following instructions should the nurse include? - ANS
-Remove clutter from rooms and hallways
- This allows the client is able to walk without the risk of falling or tripping over objects. Later in
the disease, the client can experience seizures, so cluttered areas could be a risk to the client
\A home health nurse is inspecting a client's residence for electrical hazards as part of the
agency's quality improvement plan. Which of the following findings should the nurse identify as
a safety hazard? - ANS -AN IV PUMP IS PLUGGED INTO AN OUTLET NEAR THE SINK.
- The nurse should plug all electrical appliances into outlets away from wet areas. Water
conducts electricity and places the client at risk for electrocution.
\A nurse in a long-term care facility is caring for a client who has dementia. Which of the
following actions should the nurse take? - ANS -PROVIDE FINGER FOOD AT MEALTIME.
- The nurse should provide the client who has dementia with fingers foods. Clients who have
dementia can have difficulty sitting still and tend to wander, which makes weight loss and
malnutrition a concern. Therefore, foods that the client can hold while ambulating are ideal.
\A nurse in an emergency department is assessing a client who is overusing prescribed
diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should
the nurse expect? - ANS -LOW URINE SPECFIC GRAVITY.
-A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity.
The increased excretion of water alters the ratio of particulate matter, which affects the specific
gravity.
\A nurse in an emergency department is caring for a client who is confused, has a temperature
of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke. Which of the
following actions should the nurse take first? - ANS -ADMINISTER OXYGEN USING A
HIGH-CONCENTRATION MASK.
- The first action the nurse should take when using the airway, breathing, and circulation
approach to client care is to ensure that the client has a patent airway and administer oxygen
using a high-concentration mask to promote oxygen perfusion to vital organs.
\A nurse is analyzing the ABG results of a client who is in RESPIRATORY ACIDOSIS. Which of
the following mechanisms should the nurse identify as responsible for this acid-base
imbalance? - ANS -RETENTION OF CARBON DIOXIDE.
- Retention of carbon dioxide can result from respiratory depression, inadequate chest
expansion, airway obstruction, or decreased alveolar capillary diffusion.
,\A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse
should identify which of the following findings as an indication the client is at risk for fluid volume
deficit? - ANS -SURGICAL DRAIN OUTPUT 300 ML DURING AN 8 HOUR SHIFT.
- A client who had lumbar spinal surgery should not have more than 250 mL from a drain in the
first 24 hr. Therefore, 300 mL in 8 hr can indicate that the client is at risk for fluid volume deficit.
\A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV)
fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the
IV tubing and needleless connector device are disconnected. Which of the following actions
should the nurse take first? - ANS -CLOSE THE PINCH CLAMP ON THE CVC.
- The greatest risk to this client is air embolism resulting from accidental disconnection of the
CVC tubing. Therefore, the priority action is to clamp the catheter immediately by closing the
pinch clamp to prevent any further air from entering the system. When an air embolism occurs,
air enters through the central vein into the right ventricle and lodges by the pulmonary valve,
decreasing the amount of blood that is able to enter into the ventricle and the pulmonary
arteries.
\A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage
system. Which of the following findings should the nurse report to the provider? - ANS
-CONSTANT BUBBLING IN THE WATER SEAL CHAMBER.
- Constant bubbling in the water seal chamber can be an indication of an air leak, which is
caused by a disruption in the system such as a loose connection. Pulmonary air leaks create
intermittent bubbling that is synchronous with respiration. This finding should be reported to the
provider immediately.
\A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should
identify which of the following findings as an indication of a microvascular complication? - ANS
-RETINOPATHY.
- Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting from
pathologic changes in small blood vessels, which eventually cause tissue damage, cell death in
the retina, and blindness.
\A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should
identify that which of the following findings is a manifestation of hyperglycemia? - ANS
-INCREASED THIRST.
- The nurse should teach the client that increased thirst, or polydipsia, is a manifestation of
hyperglycemia, which can lead to dehydration. Other manifestations of hyperglycemia include
an increase in appetite, or polyphagia, an increase in urine production, or polyuria, and fatigue.
\A nurse is assessing a client who has a new diagnosis of PERICARDITIS. Which of the
following findings should the nurse identify as a manifestation of cardiac tamponade? - ANS
-PARADOXICAL PULSE.
, - Cardiac tamponade results from an excess of fluid in the pericardial cavity and causes a
sudden drop in cardiac output. Paradoxical pulse is a systolic blood pressure of 10 mm Hg or
more on expiration and is a manifestation of cardiac tamponade. The nurse should report
manifestations of cardiac tamponade to the provider immediately.
\A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the
following quadrants should the nurse anticipate the client to be experiencing abdominal pain? -
ANS -LEFT LOWER QUADRANT.
- Diverticula commonly develop in the sigmoid colon because of the high pressure it takes to
move stool into the rectum. Therefore, the pain with this disorder is often in the left lower
quadrant.
\A nurse is assessing a client who has Cushing's syndrome. Which of the following findings
should the nurse expect? - ANS -Osteoporosis
Bone become thinner as a result of mineral loss & nitrogen depletion.
\A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse identify as a manifestation of left-sided heart failure? - ANS -Frothy sputum
Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be
life-threatening. Therefore, the nurse should notify the provider immediately.
\A nurse is assessing a client who has RIGHT-SIDED HEART FAILURE. Which of the following
findings should the nurse identify as a manifestation of RIGHT- SIDED HEART FAILURE? -
ANS -INCREASED ABDOMINAL GIRTH
\A nurse is assessing a client who has suspected APPENDICITIS. Which of the following
manifestations should the nurse expect? - ANS -- Elevated WBC count (20,000+)
A client who has acute appendicitis will show a moderate elevation of the WBC count from
10,000 to 18,000/mm3. If the WBC count is greater than 20,000/mm3, it can indicate a
perforated appendix.
- Rebound tenderness (RLQ)
A client who has appendicitis develops localized pain over the right lower quadrant of the
abdomen. When the area is palpated, pain occurs during release of pressure on the client's
abdomen.
- Anorexia
A client who has acute appendicitis experiences nausea, vomiting, and reduced appetite.
\A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of
the following findings is an indication to the nurse that the client is experiencing an adverse
effect of the therapy? - ANS -SKIN CHANGES.
A client who is receiving radiation therapy to the breast will have localized adverse effects of the
treatment, such as skin changes, esophagitis, and lymphedema.
\A nurse is assessing a client who recently had a myocardial infarction. Which of the following
findings indicates that the client might be developing PULMONARY EDEMA? - ANS -- Pink,
frothy sputum
- Tachypnea
