VATI Med-Surg pre-assessment Exam
Questions With Correct Answers
A nurse is preparing to administer a transfusion of RBCs to a client who has heart
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failure. For which of the following manifestations should the nurse monitor to
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prevent fluid volume overload? (Select all that apply.)
| | | | | | |
A. Dyspnea
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B. Gastrointestinal bloating
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C. Jugular vein distention
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D. Confusion
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E. Hypotension - CORRECT ANSWER✔✔-A. Dyspnea
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C. Jugular vein distention
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D. Confusion
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Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein
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distention is a clinical manifestation of fluid volume overload. Confusion is a
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clinical manifestation of fluid volume overload.
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A nurse is caring for a client who has a spinal cord injury and suspects the client is
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developing autonomic dysreflexia. Which of the following actions should the
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nurse take first?
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A. Check the client for a fecal impaction.
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B. Examine the client for areas of skin breakdown.
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,C. Check the client's bladder for distention.
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D. Place the client in a sitting position. - CORRECT ANSWER✔✔-D. Place the client
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in a sitting position.
| | | |
The nurse should use the least invasive intervention first. Therefore, the nurse
| | | | | | | | | | | |
should place the client in a sitting position to decrease the manifestation of
| | | | | | | | | | | | |
hypertension.
The nurse might have to check the client for fecal impaction, which can
| | | | | | | | | | | | |
precipitate autonomic dysreflexia. However, the nurse should use a less invasive
| | | | | | | | | | |
intervention first. The nurse might have to examine the client's skin for areas of
| | | | | | | | | | | | | |
skin breakdown or pressure, which can trigger autonomic dysreflexia. However,
| | | | | | | | | |
the nurse should use a less invasive intervention first. The nurse might have to
| | | | | | | | | | | | | |
check the client for bladder distention, which can precipitate autonomic
| | | | | | | | | |
dysreflexia. However, the nurse should use a less invasive intervention first.
| | | | | | | | | |
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
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B. Altered mental status
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C. Obesity
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D. Pain medication administration
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E. Wound infection - CORRECT ANSWER✔✔-A. Poor nutritional state
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C. Obesity
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E. Wound infection
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, 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.
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B. Turn the client every 4 hr.
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C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
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D. Perform hand hygiene prior to suctioning the client's endotracheal tube. -
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CORRECT ANSWER✔✔-C. Rinse the client's mouth with an antimicrobial solution
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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
|
Questions With Correct Answers
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 bloating
| |
C. Jugular vein distention
| | |
D. Confusion
|
E. Hypotension - CORRECT ANSWER✔✔-A. Dyspnea
| | | | |
C. Jugular vein distention
| | |
D. Confusion
|
Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein
| | | | | | | | | | |
distention is a clinical manifestation of fluid volume overload. Confusion is a
| | | | | | | | | | | |
clinical manifestation of fluid volume overload.
| | | | |
A nurse is caring for a client who has a spinal cord injury and suspects the client is
| | | | | | | | | | | | | | | | |
developing autonomic dysreflexia. Which of the following actions should the
| | | | | | | | | | |
nurse take first?
| |
A. Check the client for a fecal impaction.
| | | | | | |
B. Examine the client for areas of skin breakdown.
| | | | | | | |
,C. Check the client's bladder for distention.
| | | | | |
D. Place the client in a sitting position. - CORRECT ANSWER✔✔-D. Place the client
| | | | | | | | | | | | |
in a sitting position.
| | | |
The nurse should use the least invasive intervention first. Therefore, the nurse
| | | | | | | | | | | |
should place the client in a sitting position to decrease the manifestation of
| | | | | | | | | | | | |
hypertension.
The nurse might have to check the client for fecal impaction, which can
| | | | | | | | | | | | |
precipitate autonomic dysreflexia. However, the nurse should use a less invasive
| | | | | | | | | | |
intervention first. The nurse might have to examine the client's skin for areas of
| | | | | | | | | | | | | |
skin breakdown or pressure, which can trigger autonomic dysreflexia. However,
| | | | | | | | | |
the nurse should use a less invasive intervention first. The nurse might have to
| | | | | | | | | | | | | |
check the client for bladder distention, which can precipitate autonomic
| | | | | | | | | |
dysreflexia. However, the nurse should use a less invasive intervention first.
| | | | | | | | | |
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 - CORRECT 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. -
| | | | | | | | | | | |
CORRECT 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
|
