RN VATI Adult Medical-Surgical Assessment
Practice Exam Question and Answers with
Rationales Latest Version Top Rated A+
Question 1
A nurse is caring for a client admitted with acute heart failure. Which
assessment finding requires immediate intervention?
A. Bilateral 2+ pitting edema in the ankles
B. Blood pressure of 150/90 mm Hg
C. Crackles throughout both lung fields and oxygen saturation of 84%
D. Weight gain of 2 lb (0.9 kg) over 24 hours
Correct Answer: C. Crackles throughout both lung fields and
oxygen saturation of 84%
Rationale
This client is experiencing severe pulmonary edema, resulting in
impaired gas exchange and hypoxemia. An oxygen saturation of 84%
indicates inadequate oxygenation requiring immediate intervention.
• A: Peripheral edema indicates fluid overload but is not
immediately life-threatening.
• B: Mild hypertension is common in heart failure and is less urgent.
• D: Rapid weight gain signals worsening fluid retention but is not
as immediately dangerous as hypoxia.
Nursing Priority
,Use the ABCs (Airway, Breathing, Circulation). Oxygenation always
takes priority.
Question 2
A client with chronic kidney disease has the following laboratory results.
Which result should concern the nurse most?
A. Hemoglobin 10 g/dL
B. Potassium 6.4 mEq/L
C. BUN 48 mg/dL
D. Creatinine 3.2 mg/dL
Correct Answer: B. Potassium 6.4 mEq/L
Rationale
Hyperkalemia can rapidly produce fatal cardiac dysrhythmias.
Normal potassium:
• 3.5–5.0 mEq/L
A potassium level of 6.4 mEq/L requires immediate intervention.
• A: Mild anemia is expected with CKD.
• C: Elevated BUN reflects impaired kidney function.
• D: Elevated creatinine is expected in CKD.
Priority Nursing Actions
• Place client on cardiac monitor.
• Notify provider.
, • Prepare to administer calcium gluconate, insulin with dextrose, or
other prescribed therapies.
Question 3
A nurse is caring for a client who had a thyroidectomy 4 hours ago.
Which finding indicates possible hypocalcemia?
A. Bradycardia
B. Hoarseness
C. Positive Chvostek's sign
D. Hypertension
Correct Answer: C. Positive Chvostek's sign
Rationale
Accidental removal or injury to the parathyroid glands during thyroid
surgery may cause hypocalcemia.
Manifestations include:
• Positive Chvostek's sign
• Positive Trousseau's sign
• Muscle twitching
• Tingling
• Tetany
• Seizures
• A: Bradycardia is not a classic finding.
• B: Mild hoarseness is expected after surgery.
• D: Hypertension is unrelated.
, Question 4
A client with COPD receives oxygen at 2 L/min via nasal cannula.
Which assessment finding indicates the oxygen therapy is effective?
A. Respiratory rate decreases from 34 to 22 breaths/min
B. Oxygen saturation increases from 86% to 91%
C. Client reports less dyspnea
D. All of the above
Correct Answer: D. All of the above
Rationale
All findings indicate improved oxygenation.
Expected oxygen saturation goal for many COPD clients:
88%–92%
The nurse should also assess:
• Improved respiratory effort
• Improved comfort
• Reduced accessory muscle use
Question 5
A client develops sudden chest pain and shortness of breath following
hip replacement surgery.
Which complication should the nurse suspect first?
A. Atelectasis
Practice Exam Question and Answers with
Rationales Latest Version Top Rated A+
Question 1
A nurse is caring for a client admitted with acute heart failure. Which
assessment finding requires immediate intervention?
A. Bilateral 2+ pitting edema in the ankles
B. Blood pressure of 150/90 mm Hg
C. Crackles throughout both lung fields and oxygen saturation of 84%
D. Weight gain of 2 lb (0.9 kg) over 24 hours
Correct Answer: C. Crackles throughout both lung fields and
oxygen saturation of 84%
Rationale
This client is experiencing severe pulmonary edema, resulting in
impaired gas exchange and hypoxemia. An oxygen saturation of 84%
indicates inadequate oxygenation requiring immediate intervention.
• A: Peripheral edema indicates fluid overload but is not
immediately life-threatening.
• B: Mild hypertension is common in heart failure and is less urgent.
• D: Rapid weight gain signals worsening fluid retention but is not
as immediately dangerous as hypoxia.
Nursing Priority
,Use the ABCs (Airway, Breathing, Circulation). Oxygenation always
takes priority.
Question 2
A client with chronic kidney disease has the following laboratory results.
Which result should concern the nurse most?
A. Hemoglobin 10 g/dL
B. Potassium 6.4 mEq/L
C. BUN 48 mg/dL
D. Creatinine 3.2 mg/dL
Correct Answer: B. Potassium 6.4 mEq/L
Rationale
Hyperkalemia can rapidly produce fatal cardiac dysrhythmias.
Normal potassium:
• 3.5–5.0 mEq/L
A potassium level of 6.4 mEq/L requires immediate intervention.
• A: Mild anemia is expected with CKD.
• C: Elevated BUN reflects impaired kidney function.
• D: Elevated creatinine is expected in CKD.
Priority Nursing Actions
• Place client on cardiac monitor.
• Notify provider.
, • Prepare to administer calcium gluconate, insulin with dextrose, or
other prescribed therapies.
Question 3
A nurse is caring for a client who had a thyroidectomy 4 hours ago.
Which finding indicates possible hypocalcemia?
A. Bradycardia
B. Hoarseness
C. Positive Chvostek's sign
D. Hypertension
Correct Answer: C. Positive Chvostek's sign
Rationale
Accidental removal or injury to the parathyroid glands during thyroid
surgery may cause hypocalcemia.
Manifestations include:
• Positive Chvostek's sign
• Positive Trousseau's sign
• Muscle twitching
• Tingling
• Tetany
• Seizures
• A: Bradycardia is not a classic finding.
• B: Mild hoarseness is expected after surgery.
• D: Hypertension is unrelated.
, Question 4
A client with COPD receives oxygen at 2 L/min via nasal cannula.
Which assessment finding indicates the oxygen therapy is effective?
A. Respiratory rate decreases from 34 to 22 breaths/min
B. Oxygen saturation increases from 86% to 91%
C. Client reports less dyspnea
D. All of the above
Correct Answer: D. All of the above
Rationale
All findings indicate improved oxygenation.
Expected oxygen saturation goal for many COPD clients:
88%–92%
The nurse should also assess:
• Improved respiratory effort
• Improved comfort
• Reduced accessory muscle use
Question 5
A client develops sudden chest pain and shortness of breath following
hip replacement surgery.
Which complication should the nurse suspect first?
A. Atelectasis
