Med Surg vati assessment Questions
With Rationale
A nurse is assessing a client who has suspected appendicitis. Which of the following
manifestations should the nurse expect? (select all that apply)
Elevated WBC count
Elevated amylase level
Rebound tenderness
Ascites
Anorexia - CORRECT ANSWER ✔✔✔✔✔ Elevated WBC count
A client who has acute appendicitis will show a moderate elevation of the WBC count
from 10,000 to 18,000/mm3. If the WBC count is greater than 20,000/mm3, it can
indicate a perforated appendix.
Rebound tenderness
A client who has appendicitis develops localized pain over the right lower quadrant of
the abdomen. When the area is palpated, pain occurs during release of pressure on the
client's abdomen.
Anorexia
A client who has acute appendicitis experiences nausea, vomiting, and reduced
appetite.
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which
of the following statements by the client indicates an understanding of the teaching?
"I am aware that my diabetes is caused by an autoimmune disorder."
"I know that my diabetes developed slowly over several years."
"If I lose weight, I may be able to stop taking insulin."
"I have developed a resistance to insulin." - CORRECT ANSWER ✔✔✔✔✔ "I am
aware that my diabetes is caused by an autoimmune disorder."
Type 1 diabetes mellitus is an autoimmune disorder that destroys pancreatic beta cells.
This autoimmune reaction is often triggered by a viral infection.
A nurse is caring for a male client who has a new prescription for cyclosporine following
a kidney transplant. Which of the following findings should the nurse identify as an
adverse effect of this therapy?
WBC count 8,000/mm3
RBC count 6 million/mm3
BUN 24 mg/dL
Potassium 3.5 mEq/L - CORRECT ANSWER ✔✔✔✔✔ BUN 24 mg/dL
,A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating
renal impairment. An adverse effect of cyclosporine is nephrotoxicity. The nurse should
monitor the client for increases in BUN and creatinine and report any elevation to the
provider. A rise in BUN could indicate transplant rejection.
A nurse in a long-term care facility is caring for a client who has dementia. Which of the
following actions should the nurse take?
Give detailed directions when addressing the client.
Provide finger food at mealtime.
Use written signs to redirect the client.
Seat the client at a large table for meals. - CORRECT ANSWER ✔✔✔✔✔ Provide
finger food at mealtime.
The nurse should provide the client who has dementia with fingers foods. Clients who
have dementia can have difficulty sitting still and tend to wander, which makes weight
loss and malnutrition a concern. Therefore, foods that the client can hold while
ambulating are ideal.
A nurse is caring for a client immediately following intubation with an endotracheal (ET)
tube. Which of the following methods should the nurse identify as the most reliable for
verifying placement of the ET tube?
Feel for exhaled air emerging from the endotracheal tube.
Assess for bilateral breath sounds.
Observe for symmetric chest movement.
Check for end-tidal carbon dioxide levels. - CORRECT ANSWER ✔✔✔✔✔ Check for
end-tidal carbon dioxide levels.
According to evidence-based practice, the most reliable method for verifying ET tube
placement is checking for end-tidal carbon dioxide levels by using capnometry. A chest
x-ray is another reliable method for verifying placement.
A nurse is providing teaching for a client who has neutropenia and is receiving
chemotherapy. Which of the following client statements indicates an understanding of
the teaching? (select all that apply)
"I will avoid crowds."
"I will wash my toothbrush weekly."
"I will change my cat's litter box twice weekly."
"I will take my temperature daily."
"I will eat plenty of fresh fruits and vegetables." - CORRECT ANSWER ✔✔✔✔✔ "I will
avoid crowds."
The client who is immunocompromised should avoid crowds while undergoing
chemotherapy to reduce the risk of infection.
"I will take my temperature daily."
,The client who is immunocompromised should take daily temperature readings and
report an elevated temperature to the provider.
A nurse is planning care for a. client who has a lump in their right breast. Which of the
following findings increases the client's risk of developing breast cancer?
Menarche started at age 15
First born child was at 20 years of age
History of a fibrocystic breasts
Menopausal obesity - CORRECT ANSWER ✔✔✔✔✔ Menopausal obesity
During menopause, increased fat tissue can lead to higher stores of estrogen. Higher
levels of estrogen in the body increase the risk for postmenopausal breast cancer.
A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for
treatment of hyperthyroidism. Which of the following instructions should the nurse
include in the teaching?
Remain 0.3 m (1 ft) away from children.
Limit the time spent around women who are pregnant to 10 min daily.
Use disposable utensils for meals.
Use an absorbent pad if incontinent. - CORRECT ANSWER ✔✔✔✔✔ Use disposable
utensils for meals.
The client who receives radioactive iodine has radioactivity in the body fluids, including
saliva, for several weeks following treatment. The nurse should instruct the client to use
disposable utensils, plates, and cups during this time period to decrease the risk for
radiation exposure to other members of the household.
A nurse is providing discharge teaching to a client following a loop electrosurgical
excision procedure (LEEP) for the treatment of cervical cancer. Which of the following
statements by the client indicates an understanding of the teaching?
"I can resume sexual intercourse in 48 hours."
"I can expect some heavy vaginal bleeding for 24 hours."
"I can use tampons when my period comes in a week."
"I may have mild cramping for several hours." - CORRECT ANSWER ✔✔✔✔✔ "I may
have mild cramping for several hours."
The client should expect very little discomfort from the LEEP procedure, which is
performed in ambulatory care using a painless electrical current.
A nurse is providing teaching to a client who has a new prescription for cephalexin oral
suspension. Which of the following statements by the client indicates an understanding
of the teaching?
"I will increase my consumption of foods high in potassium."
, "I will apply lotion to my skin if I feel any itching."
"I will avoid sun exposure while taking this medication."
"I will keep the medication refrigerated." - CORRECT ANSWER ✔✔✔✔✔ "I will keep
the medication refrigerated."
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse
should identify which of the following findings as an indication of a microvascular
complication?
Coronary artery disease
Retinopathy
Cerebrovascular accident
Hypertension - CORRECT ANSWER ✔✔✔✔✔ Retinopathy
Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting from
pathologic changes in small blood vessels, which eventually cause tissue damage, cell
death in the retina, and blindness.
A nurse in an emergency department is caring for a client who is confused, has a
temperature of 104 F, a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke.
Which of the following actions should the nurse take first?
Measure the client's urine specific gravity.
Administer oxygen using a high-concentration mask.
Initiate gastric lavage with ice water.
Immerse the client in cold water. - CORRECT ANSWER ✔✔✔✔✔ Administer oxygen
using a high-concentration mask.
The first action the nurse should take when using the airway, breathing, and circulation
approach to client care is to ensure that the client has a patent airway and administer
oxygen using a high-concentration mask to promote oxygen perfusion to vital organs.
A nurse notes that a client's eyes are protruding slightly from their orbits. Which of the
following laboratory findings should the nurse expect?
Decreased calcium levels
Decreased somatotropin levels
Increased glucose levels
Increased T4 levels - CORRECT ANSWER ✔✔✔✔✔ Increased T4 levels
Exophthalmos, an abnormal protrusion of the eyeballs, is a classic sign of
hyperthyroidism. Elevated thyroid hormone levels (T3 and T4) and a decreased thyroid
stimulating hormone level reflect primary hyperthyroidism.
A nurse is providing teaching to a group of clients about the prevention of coronary
artery disease. Which of the following information should the nurse include in the
teaching?
With Rationale
A nurse is assessing a client who has suspected appendicitis. Which of the following
manifestations should the nurse expect? (select all that apply)
Elevated WBC count
Elevated amylase level
Rebound tenderness
Ascites
Anorexia - CORRECT ANSWER ✔✔✔✔✔ Elevated WBC count
A client who has acute appendicitis will show a moderate elevation of the WBC count
from 10,000 to 18,000/mm3. If the WBC count is greater than 20,000/mm3, it can
indicate a perforated appendix.
Rebound tenderness
A client who has appendicitis develops localized pain over the right lower quadrant of
the abdomen. When the area is palpated, pain occurs during release of pressure on the
client's abdomen.
Anorexia
A client who has acute appendicitis experiences nausea, vomiting, and reduced
appetite.
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which
of the following statements by the client indicates an understanding of the teaching?
"I am aware that my diabetes is caused by an autoimmune disorder."
"I know that my diabetes developed slowly over several years."
"If I lose weight, I may be able to stop taking insulin."
"I have developed a resistance to insulin." - CORRECT ANSWER ✔✔✔✔✔ "I am
aware that my diabetes is caused by an autoimmune disorder."
Type 1 diabetes mellitus is an autoimmune disorder that destroys pancreatic beta cells.
This autoimmune reaction is often triggered by a viral infection.
A nurse is caring for a male client who has a new prescription for cyclosporine following
a kidney transplant. Which of the following findings should the nurse identify as an
adverse effect of this therapy?
WBC count 8,000/mm3
RBC count 6 million/mm3
BUN 24 mg/dL
Potassium 3.5 mEq/L - CORRECT ANSWER ✔✔✔✔✔ BUN 24 mg/dL
,A BUN of 24 mg/dL is above the expected reference range of 10 to 20 mg/dL, indicating
renal impairment. An adverse effect of cyclosporine is nephrotoxicity. The nurse should
monitor the client for increases in BUN and creatinine and report any elevation to the
provider. A rise in BUN could indicate transplant rejection.
A nurse in a long-term care facility is caring for a client who has dementia. Which of the
following actions should the nurse take?
Give detailed directions when addressing the client.
Provide finger food at mealtime.
Use written signs to redirect the client.
Seat the client at a large table for meals. - CORRECT ANSWER ✔✔✔✔✔ Provide
finger food at mealtime.
The nurse should provide the client who has dementia with fingers foods. Clients who
have dementia can have difficulty sitting still and tend to wander, which makes weight
loss and malnutrition a concern. Therefore, foods that the client can hold while
ambulating are ideal.
A nurse is caring for a client immediately following intubation with an endotracheal (ET)
tube. Which of the following methods should the nurse identify as the most reliable for
verifying placement of the ET tube?
Feel for exhaled air emerging from the endotracheal tube.
Assess for bilateral breath sounds.
Observe for symmetric chest movement.
Check for end-tidal carbon dioxide levels. - CORRECT ANSWER ✔✔✔✔✔ Check for
end-tidal carbon dioxide levels.
According to evidence-based practice, the most reliable method for verifying ET tube
placement is checking for end-tidal carbon dioxide levels by using capnometry. A chest
x-ray is another reliable method for verifying placement.
A nurse is providing teaching for a client who has neutropenia and is receiving
chemotherapy. Which of the following client statements indicates an understanding of
the teaching? (select all that apply)
"I will avoid crowds."
"I will wash my toothbrush weekly."
"I will change my cat's litter box twice weekly."
"I will take my temperature daily."
"I will eat plenty of fresh fruits and vegetables." - CORRECT ANSWER ✔✔✔✔✔ "I will
avoid crowds."
The client who is immunocompromised should avoid crowds while undergoing
chemotherapy to reduce the risk of infection.
"I will take my temperature daily."
,The client who is immunocompromised should take daily temperature readings and
report an elevated temperature to the provider.
A nurse is planning care for a. client who has a lump in their right breast. Which of the
following findings increases the client's risk of developing breast cancer?
Menarche started at age 15
First born child was at 20 years of age
History of a fibrocystic breasts
Menopausal obesity - CORRECT ANSWER ✔✔✔✔✔ Menopausal obesity
During menopause, increased fat tissue can lead to higher stores of estrogen. Higher
levels of estrogen in the body increase the risk for postmenopausal breast cancer.
A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for
treatment of hyperthyroidism. Which of the following instructions should the nurse
include in the teaching?
Remain 0.3 m (1 ft) away from children.
Limit the time spent around women who are pregnant to 10 min daily.
Use disposable utensils for meals.
Use an absorbent pad if incontinent. - CORRECT ANSWER ✔✔✔✔✔ Use disposable
utensils for meals.
The client who receives radioactive iodine has radioactivity in the body fluids, including
saliva, for several weeks following treatment. The nurse should instruct the client to use
disposable utensils, plates, and cups during this time period to decrease the risk for
radiation exposure to other members of the household.
A nurse is providing discharge teaching to a client following a loop electrosurgical
excision procedure (LEEP) for the treatment of cervical cancer. Which of the following
statements by the client indicates an understanding of the teaching?
"I can resume sexual intercourse in 48 hours."
"I can expect some heavy vaginal bleeding for 24 hours."
"I can use tampons when my period comes in a week."
"I may have mild cramping for several hours." - CORRECT ANSWER ✔✔✔✔✔ "I may
have mild cramping for several hours."
The client should expect very little discomfort from the LEEP procedure, which is
performed in ambulatory care using a painless electrical current.
A nurse is providing teaching to a client who has a new prescription for cephalexin oral
suspension. Which of the following statements by the client indicates an understanding
of the teaching?
"I will increase my consumption of foods high in potassium."
, "I will apply lotion to my skin if I feel any itching."
"I will avoid sun exposure while taking this medication."
"I will keep the medication refrigerated." - CORRECT ANSWER ✔✔✔✔✔ "I will keep
the medication refrigerated."
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse
should identify which of the following findings as an indication of a microvascular
complication?
Coronary artery disease
Retinopathy
Cerebrovascular accident
Hypertension - CORRECT ANSWER ✔✔✔✔✔ Retinopathy
Diabetic retinopathy is a microvascular complication of diabetes mellitus resulting from
pathologic changes in small blood vessels, which eventually cause tissue damage, cell
death in the retina, and blindness.
A nurse in an emergency department is caring for a client who is confused, has a
temperature of 104 F, a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke.
Which of the following actions should the nurse take first?
Measure the client's urine specific gravity.
Administer oxygen using a high-concentration mask.
Initiate gastric lavage with ice water.
Immerse the client in cold water. - CORRECT ANSWER ✔✔✔✔✔ Administer oxygen
using a high-concentration mask.
The first action the nurse should take when using the airway, breathing, and circulation
approach to client care is to ensure that the client has a patent airway and administer
oxygen using a high-concentration mask to promote oxygen perfusion to vital organs.
A nurse notes that a client's eyes are protruding slightly from their orbits. Which of the
following laboratory findings should the nurse expect?
Decreased calcium levels
Decreased somatotropin levels
Increased glucose levels
Increased T4 levels - CORRECT ANSWER ✔✔✔✔✔ Increased T4 levels
Exophthalmos, an abnormal protrusion of the eyeballs, is a classic sign of
hyperthyroidism. Elevated thyroid hormone levels (T3 and T4) and a decreased thyroid
stimulating hormone level reflect primary hyperthyroidism.
A nurse is providing teaching to a group of clients about the prevention of coronary
artery disease. Which of the following information should the nurse include in the
teaching?
