MEDSURG VATI ASSESSMENT 90 EXAM QUESTIONS CORRECTLY
ANSWERED.
1. A nurse is assisting with
-A client who has chest tubes and an oxygen Sat of
the care of four clients. 90%
Which of the following
clients is the priority for Using the airway, breathing, and circulation
the nurse to see approach to client care, the nurse should determine
that the priority find- ing is the client's oxygen saturation
-A client who has chest level, which is below the expected reference range of
tubes and an oxygen Sat of 95% to 100%. Therefore, the nurse should attend to
90% this client first.
- 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
Nonresponsive Commands
2. A nurse is collecting data
from a client who was A client who has a GCS of less than 8 has evidence of
admitted with a Glasgow severe head injury and is in a comatose state. The
Coma Scale of 3. Which GCS is a stan-
of the following findings should dardized tool that allows for the evaluation of a
client's level
the nurse expect? 3. A nurse is monitoring a client
- Vacalizes sound who has a pneumothorax and a
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands
, MEDSURG VATI ASSESSMENT 90 EXAM QUESTIONS CORRECTLY
ANSWERED.
of consciousness. The test is divided into a low score of 3 (fully comatose).
three sections that evaluate eye opening,
motor response, and verbal response. The GCS
ranges from a high score of 15 (fully alert) to -Persistent bubbling in the water seal chamber
chest tube in place with a closed Excessive and persistent bubbling in the water-
seal chamber
chest drainage system connect-
, MEDSURG VATI ASSESSMENT 90 EXAM QUESTIONS CORRECTLY
ANSWERED.
ed to low suction. For which indicates an air leak in the drainage system. The nurse
should
of the following findings should notify the charge nurse of this finding.
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
wa- ter seal chamber
4. A nurse is reinforcing Comb your hair with the unattected arm
teaching with a male client
who has right sided The nurse should instruct the client to brush their
hemiparesis about hair with the unattected arm to reduce frustration
preforming ADL's. Which of and increase inde- pendence and self-esteem.
the following instructions
should the nurse include
in the teach- ing
-Comb your hair with the
unaf- fected arm
-Dress your unaffected
side first
choose clothing with
buttons
-shave with your affected
side
5. A nurse is collecting data from a - Fine crackles
, MEDSURG VATI ASSESSMENT 90 EXAM QUESTIONS CORRECTLY
ANSWERED.
client and auscultates intermit-
tent high-pitched sounds Fine crackles are auscultated in the base of the
dur- ing inspiration over lungs as air moves through airway secretions. Fine
the lower crackles are intermit-
ANSWERED.
1. A nurse is assisting with
-A client who has chest tubes and an oxygen Sat of
the care of four clients. 90%
Which of the following
clients is the priority for Using the airway, breathing, and circulation
the nurse to see approach to client care, the nurse should determine
that the priority find- ing is the client's oxygen saturation
-A client who has chest level, which is below the expected reference range of
tubes and an oxygen Sat of 95% to 100%. Therefore, the nurse should attend to
90% this client first.
- 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
Nonresponsive Commands
2. A nurse is collecting data
from a client who was A client who has a GCS of less than 8 has evidence of
admitted with a Glasgow severe head injury and is in a comatose state. The
Coma Scale of 3. Which GCS is a stan-
of the following findings should dardized tool that allows for the evaluation of a
client's level
the nurse expect? 3. A nurse is monitoring a client
- Vacalizes sound who has a pneumothorax and a
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands
, MEDSURG VATI ASSESSMENT 90 EXAM QUESTIONS CORRECTLY
ANSWERED.
of consciousness. The test is divided into a low score of 3 (fully comatose).
three sections that evaluate eye opening,
motor response, and verbal response. The GCS
ranges from a high score of 15 (fully alert) to -Persistent bubbling in the water seal chamber
chest tube in place with a closed Excessive and persistent bubbling in the water-
seal chamber
chest drainage system connect-
, MEDSURG VATI ASSESSMENT 90 EXAM QUESTIONS CORRECTLY
ANSWERED.
ed to low suction. For which indicates an air leak in the drainage system. The nurse
should
of the following findings should notify the charge nurse of this finding.
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
wa- ter seal chamber
4. A nurse is reinforcing Comb your hair with the unattected arm
teaching with a male client
who has right sided The nurse should instruct the client to brush their
hemiparesis about hair with the unattected arm to reduce frustration
preforming ADL's. Which of and increase inde- pendence and self-esteem.
the following instructions
should the nurse include
in the teach- ing
-Comb your hair with the
unaf- fected arm
-Dress your unaffected
side first
choose clothing with
buttons
-shave with your affected
side
5. A nurse is collecting data from a - Fine crackles
, MEDSURG VATI ASSESSMENT 90 EXAM QUESTIONS CORRECTLY
ANSWERED.
client and auscultates intermit-
tent high-pitched sounds Fine crackles are auscultated in the base of the
dur- ing inspiration over lungs as air moves through airway secretions. Fine
the lower crackles are intermit-
