VATI Med-Surg pre-assessment Practice Questions
and Answers
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for
clients who have surgical incisions. Which of the following factors should the
nurse include in the teaching? (Select all that apply.)
A. Poor nutritional state
B. Altered mental status
C. Obesity
D. Pain medication administration
E. Wound infection - ANSWER -A. Poor nutritional state
C. Obesity
E. Wound infection
A nurse is caring for a client who has an endotracheal tube and is receiving
mechanical ventilation. Which of the following interventions should the nurse take
to reduce the risk for ventilator-associated pneumonia?
A. Position the head of the client's bed in the flat position.
B. Turn the client every 4 hr.
C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
D. Perform hand hygiene prior to suctioning the client's endotracheal tube. -
ANSWER -C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
The nurse should brush the client's teeth every 8 hr and rinse the client's mouth
with an antimicrobial rinse every 2 hr to reduce the growth of bacteria.
The nurse should elevate the head of the client's bed 30° to reduce the risk for
aspiration and pneumonia. The nurse should turn the client every 2 hr to promote
lung expansion and reduce the risk for pneumonia. The nurse should perform hand
hygiene prior to suctioning the client's endotracheal tube to reduce the risk of
introducing bacteria.
, A nurse is providing instruction to a new nurse about caring for clients who are
receiving diuretic therapy to treat heart failure. The nurse should explain that
which of the following medications puts clients at risk for both hyperkalemia and
hyponatremia?
A. Furosemide
B. Hydrochlorothiazide
C. Metolazone
D. Spironolactone - ANSWER -D. Spironolactone
Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone
in the renal tubules, causing a loss of sodium and water and the retention of
potassium. The possible adverse reactions include hyperkalemia and hyponatremia.
Furosemide is a high-ceiling (loop) diuretic that increases the risk of hyponatremia
and hypokalemia, not hyperkalemia. Hydrochlorothiazide is a thiazide diuretic that
increases the risk of hypokalemia, not hyperkalemia. Metolazone is a thiazide
diuretic that increases the risk of hyponatremia and hypokalemia, not
hyperkalemia.
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which
of the following findings should the nurse recognize as a risk factor for this
medication?
A. History of bulimia
B. History of NSAID use
C. Drinks green tea
D. Has a glass of wine with dinner each day - ANSWER -B. History of NSAID
use
The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic
ulcer disease. NSAIDs break down the mucosal barrier and cause production of
prostaglandins to decrease, which results in local gastric mucosal injury.
, A nurse is planning care for a client following a cardiac catheterization accessed
through his femoral artery. Which of the following actions should the plan to take?
A. Instruct the client to perform range-of-motion exercises to his lower extremities.
B. Perform neurovascular checks with vital signs.
C. Ambulate the client 1 hr following the procedure.
D. Restrict the client's fluid intake. - ANSWER -B. Perform neurovascular checks
with vital signs.
The nurse should assess color, temperature, and pulse in the affected extremity and
monitor the client for neurovascular changes that can indicate a stroke, such as
slurred speech and visual disturbances.
The client should keep the extremity of the insertion site straight to reduce the risk
for bleeding. A knee brace might be used to restrict movement. The client should
remain on bed rest for 2 to 6 hr following the procedure to reduce the risk for
bleeding. The nurse should increase fluid intake following a cardiac catheterization
to promote excretion of the contrast medium and reduce the risk for dehydration.
A nurse is caring for a client who is receiving IV fluids to correct dehydration.
Which of the following laboratory values should indicate to the nurse that the
client is effectively responding to treatment?
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% - ANSWER -C. Urine specific gravity 1.020
In cases of dehydration or fluid volume deficit, the kidney reabsorbs all available
water, making the urine more concentrated and increasing the urine specific
gravity. A level of 1.020 is within the expected reference range of 1.005 to 1.030,
which indicates that the treatment is effective.
The nurse is caring for a client with chronic kidney disease.
and Answers
A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for
clients who have surgical incisions. Which of the following factors should the
nurse include in the teaching? (Select all that apply.)
A. Poor nutritional state
B. Altered mental status
C. Obesity
D. Pain medication administration
E. Wound infection - ANSWER -A. Poor nutritional state
C. Obesity
E. Wound infection
A nurse is caring for a client who has an endotracheal tube and is receiving
mechanical ventilation. Which of the following interventions should the nurse take
to reduce the risk for ventilator-associated pneumonia?
A. Position the head of the client's bed in the flat position.
B. Turn the client every 4 hr.
C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
D. Perform hand hygiene prior to suctioning the client's endotracheal tube. -
ANSWER -C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
The nurse should brush the client's teeth every 8 hr and rinse the client's mouth
with an antimicrobial rinse every 2 hr to reduce the growth of bacteria.
The nurse should elevate the head of the client's bed 30° to reduce the risk for
aspiration and pneumonia. The nurse should turn the client every 2 hr to promote
lung expansion and reduce the risk for pneumonia. The nurse should perform hand
hygiene prior to suctioning the client's endotracheal tube to reduce the risk of
introducing bacteria.
, A nurse is providing instruction to a new nurse about caring for clients who are
receiving diuretic therapy to treat heart failure. The nurse should explain that
which of the following medications puts clients at risk for both hyperkalemia and
hyponatremia?
A. Furosemide
B. Hydrochlorothiazide
C. Metolazone
D. Spironolactone - ANSWER -D. Spironolactone
Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone
in the renal tubules, causing a loss of sodium and water and the retention of
potassium. The possible adverse reactions include hyperkalemia and hyponatremia.
Furosemide is a high-ceiling (loop) diuretic that increases the risk of hyponatremia
and hypokalemia, not hyperkalemia. Hydrochlorothiazide is a thiazide diuretic that
increases the risk of hypokalemia, not hyperkalemia. Metolazone is a thiazide
diuretic that increases the risk of hyponatremia and hypokalemia, not
hyperkalemia.
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which
of the following findings should the nurse recognize as a risk factor for this
medication?
A. History of bulimia
B. History of NSAID use
C. Drinks green tea
D. Has a glass of wine with dinner each day - ANSWER -B. History of NSAID
use
The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic
ulcer disease. NSAIDs break down the mucosal barrier and cause production of
prostaglandins to decrease, which results in local gastric mucosal injury.
, A nurse is planning care for a client following a cardiac catheterization accessed
through his femoral artery. Which of the following actions should the plan to take?
A. Instruct the client to perform range-of-motion exercises to his lower extremities.
B. Perform neurovascular checks with vital signs.
C. Ambulate the client 1 hr following the procedure.
D. Restrict the client's fluid intake. - ANSWER -B. Perform neurovascular checks
with vital signs.
The nurse should assess color, temperature, and pulse in the affected extremity and
monitor the client for neurovascular changes that can indicate a stroke, such as
slurred speech and visual disturbances.
The client should keep the extremity of the insertion site straight to reduce the risk
for bleeding. A knee brace might be used to restrict movement. The client should
remain on bed rest for 2 to 6 hr following the procedure to reduce the risk for
bleeding. The nurse should increase fluid intake following a cardiac catheterization
to promote excretion of the contrast medium and reduce the risk for dehydration.
A nurse is caring for a client who is receiving IV fluids to correct dehydration.
Which of the following laboratory values should indicate to the nurse that the
client is effectively responding to treatment?
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% - ANSWER -C. Urine specific gravity 1.020
In cases of dehydration or fluid volume deficit, the kidney reabsorbs all available
water, making the urine more concentrated and increasing the urine specific
gravity. A level of 1.020 is within the expected reference range of 1.005 to 1.030,
which indicates that the treatment is effective.
The nurse is caring for a client with chronic kidney disease.
