2023 VATI MEDICAL SURGICAL
ASSESSMENT GUARANTEED
PASS A QUESTIONS/ANSWERS
A client is admitted to the surgical unit after sustaining a compound fracture of the left
femur. The client is alert and oriented with the following vital signs: T 99.4 F, P 88, R 20,
B/P 94/58. The nurse notes a 4 cm. area of bright red blood on the pressure dressing
on the left lower extremity. The client is receiving intravenous fluids of normal saline at
150 ml/hr. One hour after being admitted to the unit, the nurse finds the client confused
and combative. Which of the following is the most likely cause of the change in the
client's condition?
Select one:
a. Hypovolemic shock related to hemorrhage from the open wound
c. Fluid overload related to aggressive isotonic volume replacement
d. Hypoxia related to fat embolism from the fractured bone. - ANSWER-d. Hypoxia
related to fat embolism from the fractured bone
A nurse is caring for a client on the telemetry unit who is two days post coronary artery
bypass grafting (CABG). The nurse recognizes a cardiac rhythm change from normal
sinus rhythm to atrial fibrillation. Which of the following should be completed first?
Select one:
a. Prepare a diltizem drip.
b. Prepare the client for cardioversion.
c. Notify the health care provider.
d. Assess the client's blood pressure. - ANSWER-d. Assess the client's blood pressure.
The nurse is planning care for a client who is prescribed antiembolic stocking following
abdominal surgery. Which of the following interventions should the nurse include?
Select one:
a. Remove stocking every 2 hours then reapply after 1 hour off.
b. Ensure stockings are loose fitting over client's calves.
c. Encourage client to only wear stockings when out of bed.
d. Remove stockings one to three times per day for skin care and inspection. -
ANSWER-The correct answer is: Remove stockings one to three times per day for skin
care and inspection.
,A nurse is caring for a client with Addison's disease. Which of the following diets should
the nurse teach the client to follow?
Select one:
a. High Sodium, low calcium and increased fluids.
b. Low Sodium, high calcium and decreased fluids.
c. Low Sodium, high potassium and decreased fluids. .
d. High Sodium, low potassium and increased fluids. - ANSWER-High Sodium, low
potassium and increased fluids.
A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L. Which
nursing action would be most appropriate at this time?
Select one:
a. Provide oral hygiene and comfort measures.
b. Monitor for diminished breath sounds.
c. Encourage water and other fluids.
d. Administer 0.9% Normal Saline - ANSWER-d. Administer 0.9% Normal Saline.
Administering of isotonic IV therapy would be appropriate at this time for restoration of
normal ECF volume.
A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed
aqueous vasopressin. Which of the following outcomes indicates that treatment has
been effective?
Select one:
a. Fluid intake of 2,400mL in 24 hours
b. Pulse rate of 126 beats/minute
c. Blood pressure of 90/50 mm Hg
d. Urine output of 200mL per hour - ANSWER-a. Fluid intake of 2,400mL in 24 hours
DI is characterized by polyuria (up to 8L/day), constant thirst, and an unusually high oral
intake of fluids. Treatment with Lypressin should decrease the urine output and oral fluid
intake.
Which of the following should the nurse use to determine the neurological status of a
client with a head injury?
Select one:
a. Client's reported pain scale
b. The Glasgow Coma Scale
c. Respiratory rate
d. Manifestations of seizure activity - ANSWER-. The Glasgow Coma Scale
, The Glasgow Coma Scale (GCS) is used to determine the client's level of
consciousness (LOC). This is done with a head injury client at regular intervals,
because LOC changes precede all other changes in vital and neurological signs. Each
response is scored to predetermined criteria. The score is calculated numerically and
the higher the score the higher the functioning.
A client is admitted to the medical unit from the convalescent center for treatment of
urosepsis. The client's adult daughter reports to the nurse, "I don't know what to do. I
love my mom and would like to have her live in my home, but I just can't be with her
every minute, and that's what she needs now." Which of the following would be the best
approach to improve integration of the elderly mother into the family structure?
Select one:
a. Determine if the daughter would consider having the client visit in her home one day
a week.
b. Offer to refer the daughter to a counselor in an effort to better deal with her feelings of
guilt.
c. Suggest that the daughter move the client into the family home on a trial basis for
several weeks.
d. Assist the daughter in finding a caregiver who can assist the client in the
convalescent center. - ANSWER-a. Determine if the daughter would consider having
the client visit in her home one day a week.
A nurse is reviewing a client's lab results. Which finding would lead the nurse to suspect
the client is experiencing dehydration?
Select one:
a. Hematocrit 55%
b. Serum sodium 130 mEq/L
c. Urine specific gravity of 1.025
d. BUN 20mg/100mL - ANSWER-a. Hematocrit 55%
A nurse is caring for a toddler who is being treated for hypovolemia. Which of the
following demonstrates to the nurse the desired response to fluid replacement?
Select one:
a. Central Venous Pressure 2 mm Hg
b. Urine output 48 mL for the past 4 hours
c. Apical heart rate 130 beats/min
d. Specific Gravity 1.025 - ANSWER-d. Specific Gravity 1.025
Specific gravity falls within normal range of 1.010-1.030 and indicates successful fluid
replacement.
ASSESSMENT GUARANTEED
PASS A QUESTIONS/ANSWERS
A client is admitted to the surgical unit after sustaining a compound fracture of the left
femur. The client is alert and oriented with the following vital signs: T 99.4 F, P 88, R 20,
B/P 94/58. The nurse notes a 4 cm. area of bright red blood on the pressure dressing
on the left lower extremity. The client is receiving intravenous fluids of normal saline at
150 ml/hr. One hour after being admitted to the unit, the nurse finds the client confused
and combative. Which of the following is the most likely cause of the change in the
client's condition?
Select one:
a. Hypovolemic shock related to hemorrhage from the open wound
c. Fluid overload related to aggressive isotonic volume replacement
d. Hypoxia related to fat embolism from the fractured bone. - ANSWER-d. Hypoxia
related to fat embolism from the fractured bone
A nurse is caring for a client on the telemetry unit who is two days post coronary artery
bypass grafting (CABG). The nurse recognizes a cardiac rhythm change from normal
sinus rhythm to atrial fibrillation. Which of the following should be completed first?
Select one:
a. Prepare a diltizem drip.
b. Prepare the client for cardioversion.
c. Notify the health care provider.
d. Assess the client's blood pressure. - ANSWER-d. Assess the client's blood pressure.
The nurse is planning care for a client who is prescribed antiembolic stocking following
abdominal surgery. Which of the following interventions should the nurse include?
Select one:
a. Remove stocking every 2 hours then reapply after 1 hour off.
b. Ensure stockings are loose fitting over client's calves.
c. Encourage client to only wear stockings when out of bed.
d. Remove stockings one to three times per day for skin care and inspection. -
ANSWER-The correct answer is: Remove stockings one to three times per day for skin
care and inspection.
,A nurse is caring for a client with Addison's disease. Which of the following diets should
the nurse teach the client to follow?
Select one:
a. High Sodium, low calcium and increased fluids.
b. Low Sodium, high calcium and decreased fluids.
c. Low Sodium, high potassium and decreased fluids. .
d. High Sodium, low potassium and increased fluids. - ANSWER-High Sodium, low
potassium and increased fluids.
A nurse is caring for a client who is experiencing a sodium level of 119 mEq/L. Which
nursing action would be most appropriate at this time?
Select one:
a. Provide oral hygiene and comfort measures.
b. Monitor for diminished breath sounds.
c. Encourage water and other fluids.
d. Administer 0.9% Normal Saline - ANSWER-d. Administer 0.9% Normal Saline.
Administering of isotonic IV therapy would be appropriate at this time for restoration of
normal ECF volume.
A nurse is caring for a client with diabetes insipidus (DI) who has been prescribed
aqueous vasopressin. Which of the following outcomes indicates that treatment has
been effective?
Select one:
a. Fluid intake of 2,400mL in 24 hours
b. Pulse rate of 126 beats/minute
c. Blood pressure of 90/50 mm Hg
d. Urine output of 200mL per hour - ANSWER-a. Fluid intake of 2,400mL in 24 hours
DI is characterized by polyuria (up to 8L/day), constant thirst, and an unusually high oral
intake of fluids. Treatment with Lypressin should decrease the urine output and oral fluid
intake.
Which of the following should the nurse use to determine the neurological status of a
client with a head injury?
Select one:
a. Client's reported pain scale
b. The Glasgow Coma Scale
c. Respiratory rate
d. Manifestations of seizure activity - ANSWER-. The Glasgow Coma Scale
, The Glasgow Coma Scale (GCS) is used to determine the client's level of
consciousness (LOC). This is done with a head injury client at regular intervals,
because LOC changes precede all other changes in vital and neurological signs. Each
response is scored to predetermined criteria. The score is calculated numerically and
the higher the score the higher the functioning.
A client is admitted to the medical unit from the convalescent center for treatment of
urosepsis. The client's adult daughter reports to the nurse, "I don't know what to do. I
love my mom and would like to have her live in my home, but I just can't be with her
every minute, and that's what she needs now." Which of the following would be the best
approach to improve integration of the elderly mother into the family structure?
Select one:
a. Determine if the daughter would consider having the client visit in her home one day
a week.
b. Offer to refer the daughter to a counselor in an effort to better deal with her feelings of
guilt.
c. Suggest that the daughter move the client into the family home on a trial basis for
several weeks.
d. Assist the daughter in finding a caregiver who can assist the client in the
convalescent center. - ANSWER-a. Determine if the daughter would consider having
the client visit in her home one day a week.
A nurse is reviewing a client's lab results. Which finding would lead the nurse to suspect
the client is experiencing dehydration?
Select one:
a. Hematocrit 55%
b. Serum sodium 130 mEq/L
c. Urine specific gravity of 1.025
d. BUN 20mg/100mL - ANSWER-a. Hematocrit 55%
A nurse is caring for a toddler who is being treated for hypovolemia. Which of the
following demonstrates to the nurse the desired response to fluid replacement?
Select one:
a. Central Venous Pressure 2 mm Hg
b. Urine output 48 mL for the past 4 hours
c. Apical heart rate 130 beats/min
d. Specific Gravity 1.025 - ANSWER-d. Specific Gravity 1.025
Specific gravity falls within normal range of 1.010-1.030 and indicates successful fluid
replacement.
