VATI MED-SURG PRE-ASSESSMENT |40 COMPLETE QUESTIONS AND ANSWERS | 2026
LATEST UPDATED| 100% RATED CORRECT | GET A+!!
1. 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: 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.
2. 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.: 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.
3. 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: A. Poor nutritional state
C. Obesity
E. Wound infection
, 4. 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.:
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
LATEST UPDATED| 100% RATED CORRECT | GET A+!!
1. 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: 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.
2. 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.: 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.
3. 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: A. Poor nutritional state
C. Obesity
E. Wound infection
, 4. 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.:
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
