ASSESSMENT RN VATI ADULT
MEDICAL SURGICAL 2026
2027 VERIFIED ANSWERS
ACTUAL UPDATED PRACTICE
QUESTIONS TEST BANK HIGH
YIELD STUDY GUIDE EXAM
PREP MATERIAL LATEST
VERSION FOR NURSING
SUCCESS GRADED A+
1. Inspect the client's skin underneath the boot every 12 hr.
The nurse should inspect the client’s skin underneath the boot every 8 hr for irritation, increased swelling,
and skin breakdown.
Remove the weights from the traction while repositioning the client in bed.
MY ANSWER
The nurse should not remove the weights from traction without a prescription from the provider.
The purpose of the weight is to immobilize the hip prior to surgery and to decrease muscles
spasms.
Assess the client's circulation every 4 hr.
The nurse should assess the client's circulation hourly for the first 24 hr to monitor for decreased perfusion
and neurovascular changes.
Request the client to perform dorsiflexion of the affected extremity every 1 hr.
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EXAM QUESTIONS AND CORRECT DETAILED
The nurse should request the client to perform dorsiflexion of the affected extremity every 1 hr
to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate
peroneal nerve damage. If this occurs, the nurse should notify the provider immediately.
2. Stop the blood transfusion immediately.
A client who has type AB-positive blood is considered a universal recipient and can receive any
ABO blood type. A client who has Rh-positive blood can receive a transfusion from a Rh-negative
donor.
Prepare to administer antipyretics.
Febrile reactions are most often caused by leukocyte incompatibilities. Unless a client has a
history of febrile reactions to prior transfusions or shows signs of chills or fever, there is no
reason to administer antipyretics.
Monitor the client for any adverse reactions.
MY ANSWER
Although a client is considered a universal recipient because he can receive any ABO blood type,
the nurse should continue to monitor the client for any adverse reactions, which is standard
procedure for any blood transfusion.
Transfuse the blood over 6 hr.
The nurse should transfuse the packed RBCs within 4 hr after removing it from refrigeration to reduce
the risk of bacterial contamination of the blood.
3. Assess the client to determine the need for endotracheal suction every 4 hr.
Evidence-based practice indicates the nurse should assess the client's need for endotracheal suction
every 2 hr to ensure a clear airway.
Check the ventilator settings every 12 hr.
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Assessment RN VATI Adult Medical Surgical 2016
REAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
Evidence-based practice indicates the nurse should check the ventilator settings every 8 hr to make
sure the settings are at the correct levels.
Keep the head of the client's bed elevated 30°.
MY ANSWER
The nurse should keep the head of the client's bed elevated at least 30° to promote increased lung
expansion and to help prevent ventilator-associated pneumonia.
Perform oral hygiene with chlorhexidine every 3 hr.
Evidence-based practice indicates the nurse should perform oral hygiene with chlorhexidine
every 2 hr to help prevent ventilator-associated pneumonia from bacteria accumulating in the
oral cavity and colonizing in the lower respiratory system.
4. High lipase
A high lipase level is associated with pancreatic dysfunction or renal failure and is not an expected
finding of hyponatremia or dehydration.
Low urine specific gravity
MY ANSWER
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Assessment RN VATI Adult Medical Surgical 2016
REAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
A client who has hyponatremia as a result of diuretic overuse will have a low urine specific
gravity. The increased excretion of water alters the ratio of particulate matter, which affects the
specific gravity.
Low hemoglobin
A client who is dehydrated as a result of diuretic overuse can have an elevated hemoglobin level
because of the difference in ratio between intravascular fluid and blood cells.
High creatine kinase-MB (CK-MB)
An elevated CK-MB level indicates a myocardial infarction has occurred and is not an expected
finding of hyponatremia.
5. "I will adjust the rate of infusion based on my urinary output."
The nurse should teach the client to monitor urinary output. However, the client should
administer PN at a consistent rate prescribed by the provider. An infusion rate that is too rapid
can cause hyperosmolar diuresis and hyperglycemia. A rate that is too slow can result in
inadequate caloric and nutritional intake.
"I will need to have a 60-milliliter syringe to administer my PN."
The nurse should teach the client to use an electronic infusion device to prevent the accidental
overload of the intravenous PN solution. A 60-mL syringe is used for intermittent bolus enteral
tube feedings.
"I will keep additional solution bags at room temperature."
The nurse should teach the client to refrigerate any PN solution that is not infusing to decrease
the risk of bacterial growth. PN solution is an ideal environment for bacterial growth because of
the high dextrose and fat content.
"I will use aseptic technique when administering my PN."
MY ANSWER
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MEDICAL SURGICAL 2026
2027 VERIFIED ANSWERS
ACTUAL UPDATED PRACTICE
QUESTIONS TEST BANK HIGH
YIELD STUDY GUIDE EXAM
PREP MATERIAL LATEST
VERSION FOR NURSING
SUCCESS GRADED A+
1. Inspect the client's skin underneath the boot every 12 hr.
The nurse should inspect the client’s skin underneath the boot every 8 hr for irritation, increased swelling,
and skin breakdown.
Remove the weights from the traction while repositioning the client in bed.
MY ANSWER
The nurse should not remove the weights from traction without a prescription from the provider.
The purpose of the weight is to immobilize the hip prior to surgery and to decrease muscles
spasms.
Assess the client's circulation every 4 hr.
The nurse should assess the client's circulation hourly for the first 24 hr to monitor for decreased perfusion
and neurovascular changes.
Request the client to perform dorsiflexion of the affected extremity every 1 hr.
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of this document is illegal extra per year?
,Assessment RN VATI Adult Medical Surgical 2016 REAL
EXAM QUESTIONS AND CORRECT DETAILED
The nurse should request the client to perform dorsiflexion of the affected extremity every 1 hr
to assess if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate
peroneal nerve damage. If this occurs, the nurse should notify the provider immediately.
2. Stop the blood transfusion immediately.
A client who has type AB-positive blood is considered a universal recipient and can receive any
ABO blood type. A client who has Rh-positive blood can receive a transfusion from a Rh-negative
donor.
Prepare to administer antipyretics.
Febrile reactions are most often caused by leukocyte incompatibilities. Unless a client has a
history of febrile reactions to prior transfusions or shows signs of chills or fever, there is no
reason to administer antipyretics.
Monitor the client for any adverse reactions.
MY ANSWER
Although a client is considered a universal recipient because he can receive any ABO blood type,
the nurse should continue to monitor the client for any adverse reactions, which is standard
procedure for any blood transfusion.
Transfuse the blood over 6 hr.
The nurse should transfuse the packed RBCs within 4 hr after removing it from refrigeration to reduce
the risk of bacterial contamination of the blood.
3. Assess the client to determine the need for endotracheal suction every 4 hr.
Evidence-based practice indicates the nurse should assess the client's need for endotracheal suction
every 2 hr to ensure a clear airway.
Check the ventilator settings every 12 hr.
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Assessment RN VATI Adult Medical Surgical 2016
REAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
Evidence-based practice indicates the nurse should check the ventilator settings every 8 hr to make
sure the settings are at the correct levels.
Keep the head of the client's bed elevated 30°.
MY ANSWER
The nurse should keep the head of the client's bed elevated at least 30° to promote increased lung
expansion and to help prevent ventilator-associated pneumonia.
Perform oral hygiene with chlorhexidine every 3 hr.
Evidence-based practice indicates the nurse should perform oral hygiene with chlorhexidine
every 2 hr to help prevent ventilator-associated pneumonia from bacteria accumulating in the
oral cavity and colonizing in the lower respiratory system.
4. High lipase
A high lipase level is associated with pancreatic dysfunction or renal failure and is not an expected
finding of hyponatremia or dehydration.
Low urine specific gravity
MY ANSWER
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Assessment RN VATI Adult Medical Surgical 2016
REAL EXAM QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (VERIFIED
ANSWERS)
A client who has hyponatremia as a result of diuretic overuse will have a low urine specific
gravity. The increased excretion of water alters the ratio of particulate matter, which affects the
specific gravity.
Low hemoglobin
A client who is dehydrated as a result of diuretic overuse can have an elevated hemoglobin level
because of the difference in ratio between intravascular fluid and blood cells.
High creatine kinase-MB (CK-MB)
An elevated CK-MB level indicates a myocardial infarction has occurred and is not an expected
finding of hyponatremia.
5. "I will adjust the rate of infusion based on my urinary output."
The nurse should teach the client to monitor urinary output. However, the client should
administer PN at a consistent rate prescribed by the provider. An infusion rate that is too rapid
can cause hyperosmolar diuresis and hyperglycemia. A rate that is too slow can result in
inadequate caloric and nutritional intake.
"I will need to have a 60-milliliter syringe to administer my PN."
The nurse should teach the client to use an electronic infusion device to prevent the accidental
overload of the intravenous PN solution. A 60-mL syringe is used for intermittent bolus enteral
tube feedings.
"I will keep additional solution bags at room temperature."
The nurse should teach the client to refrigerate any PN solution that is not infusing to decrease
the risk of bacterial growth. PN solution is an ideal environment for bacterial growth because of
the high dextrose and fat content.
"I will use aseptic technique when administering my PN."
MY ANSWER
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