VATI MED-SURG PRE-ASSESSMENT
EXAM WITH CORRECT ANSWERS 2025
A nurse is preparing to administer a transfusion of RBCs to a client who
has heart
failure. For which of the following manifestations should the nurse monitor
to prevent
fluid volume overload? (Select all that
apply.)
A.
Dyspnea
B. Gastrointestinal
C. Jugular vein
bloating
distention
D.
E. Hypotension ( Correct answers ) A.
Confusion
Dyspnea
C. Jugular vein
D.
distention
Confusion
Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein
distention
clinical is a
manifestation of fluid volume overload. Confusion is a clinical
manifestation
fluid volume of
overload.
A nurse is caring for a client who has a spinal cord injury and suspects
the client is autonomic dysreflexia. Which of the following actions should the
developing
nurse take
first
?
A. Check the client for a fecal
impaction.
B. Examine the client for areas of skin
C. Check the client's bladder for
breakdown.
distention.
D. Place the client in a sitting position. ( Correct answers ) D. Place the
client in a
sitting
position.
The nurse should use the least invasive intervention first. Therefore, the
nurse the
place should
client in a sitting position to decrease the manifestation of
hypertension.
The nurse might have to check the client for fecal impaction, which can
autonomic dysreflexia. However, the nurse should use a less invasive
precipitate
intervention
The first.have to examine the client's skin for areas of skin
nurse might
pressure,
breakdown which
or can trigger autonomic dysreflexia. However, the nurse
should
less use a intervention first. The nurse might have to check the client
invasive
for bladder which can precipitate autonomic dysreflexia. However, the nurse
distention,
should
a use
less invasive intervention
first.
, A nurse is teaching a newly licensed nurse about the risk factors for
dehiscence
clients who have
for surgical incisions. Which of the following factors should
the nurse
include in the teaching? (Select all that
apply.)
A. Poor nutritional
B. Altered mental
state
status
C.
D. Pain medication
Obesity
administration
E. Wound infection ( Correct answers ) A. Poor
nutritional state
C.
Obesity
E. Wound
infection
A nurse is caring for a client who has an endotracheal tube and is receiving
ventilation. Which of the following interventions should the nurse take to
mechanical
reduce the risk
for ventilator-associated
pneumonia?
A. Position the head of the client's bed in the flat
B. Turn the client every
position.
4 hr.
C. Rinse the client's mouth with an antimicrobial solution
every
D. Perform
4 hr. hand hygiene prior to suctioning the client's endotracheal
tube. ( Correct
answers ) 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 anrinse every 2 hr to reduce the growth of
antimicrobial
bacteria.
The nurse should elevate the head of the client's bed 30° to reduce
the risk forand pneumonia. The nurse should turn the client every 2 hr to
aspiration
promote lung
expansion and reduce the risk for pneumonia. The nurse should perform
hand to
prior hygiene
suctioning the client's endotracheal tube to reduce the risk of
bacteri
introducing
a.
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.
C.
Hydrochlorothiazide
Metolazone
D. Spironolactone ( Correct answers ) D.
Spironolactone
Spironolactone is a potassium-sparing diuretic. It blocks the effects of
aldosterone
renal tubules, in causing
the a loss of sodium and water and the retention of
potassium.
possible The reactions include hyperkalemia and
adverse
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
EXAM WITH CORRECT ANSWERS 2025
A nurse is preparing to administer a transfusion of RBCs to a client who
has heart
failure. For which of the following manifestations should the nurse monitor
to prevent
fluid volume overload? (Select all that
apply.)
A.
Dyspnea
B. Gastrointestinal
C. Jugular vein
bloating
distention
D.
E. Hypotension ( Correct answers ) A.
Confusion
Dyspnea
C. Jugular vein
D.
distention
Confusion
Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein
distention
clinical is a
manifestation of fluid volume overload. Confusion is a clinical
manifestation
fluid volume of
overload.
A nurse is caring for a client who has a spinal cord injury and suspects
the client is autonomic dysreflexia. Which of the following actions should the
developing
nurse take
first
?
A. Check the client for a fecal
impaction.
B. Examine the client for areas of skin
C. Check the client's bladder for
breakdown.
distention.
D. Place the client in a sitting position. ( Correct answers ) D. Place the
client in a
sitting
position.
The nurse should use the least invasive intervention first. Therefore, the
nurse the
place should
client in a sitting position to decrease the manifestation of
hypertension.
The nurse might have to check the client for fecal impaction, which can
autonomic dysreflexia. However, the nurse should use a less invasive
precipitate
intervention
The first.have to examine the client's skin for areas of skin
nurse might
pressure,
breakdown which
or can trigger autonomic dysreflexia. However, the nurse
should
less use a intervention first. The nurse might have to check the client
invasive
for bladder which can precipitate autonomic dysreflexia. However, the nurse
distention,
should
a use
less invasive intervention
first.
, A nurse is teaching a newly licensed nurse about the risk factors for
dehiscence
clients who have
for surgical incisions. Which of the following factors should
the nurse
include in the teaching? (Select all that
apply.)
A. Poor nutritional
B. Altered mental
state
status
C.
D. Pain medication
Obesity
administration
E. Wound infection ( Correct answers ) A. Poor
nutritional state
C.
Obesity
E. Wound
infection
A nurse is caring for a client who has an endotracheal tube and is receiving
ventilation. Which of the following interventions should the nurse take to
mechanical
reduce the risk
for ventilator-associated
pneumonia?
A. Position the head of the client's bed in the flat
B. Turn the client every
position.
4 hr.
C. Rinse the client's mouth with an antimicrobial solution
every
D. Perform
4 hr. hand hygiene prior to suctioning the client's endotracheal
tube. ( Correct
answers ) 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 anrinse every 2 hr to reduce the growth of
antimicrobial
bacteria.
The nurse should elevate the head of the client's bed 30° to reduce
the risk forand pneumonia. The nurse should turn the client every 2 hr to
aspiration
promote lung
expansion and reduce the risk for pneumonia. The nurse should perform
hand to
prior hygiene
suctioning the client's endotracheal tube to reduce the risk of
bacteri
introducing
a.
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.
C.
Hydrochlorothiazide
Metolazone
D. Spironolactone ( Correct answers ) D.
Spironolactone
Spironolactone is a potassium-sparing diuretic. It blocks the effects of
aldosterone
renal tubules, in causing
the a loss of sodium and water and the retention of
potassium.
possible The reactions include hyperkalemia and
adverse
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
