VATI Med-Surg pre-assessment
QUESTIONS AND ALL CORRECT
ANSWERS 100% SOLVED AND
GUARANTEED SUCCESS!!
Question 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
Correct Answer(s): A, C, D
Rationale:
• A. Dyspnea – Indicates pulmonary congestion caused by fluid overload.
• B. Gastrointestinal bloating ✘ – Not a classic manifestation of fluid volume overload
during blood transfusion.
• C. Jugular vein distention – Elevated venous pressure causes neck vein distention, a
hallmark of fluid overload.
• D. Confusion – Reduced oxygenation from pulmonary edema can lead to altered
mental status.
• E. Hypotension ✘ – Fluid overload more commonly causes hypertension rather than
hypotension.
Exam Tip: During blood transfusions, monitor clients with heart failure closely for TACO
(Transfusion-Associated Circulatory Overload). Early signs include dyspnea, JVD, crackles,
hypertension, and confusion.
,Question 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.
Correct Answer: D. Place the client in a sitting position
Rationale
• A. Check the client for a fecal impaction ✘
o Fecal impaction is a common trigger of autonomic dysreflexia, but it is not the
first action. The nurse should first reduce the dangerously high blood pressure.
• B. Examine the client for areas of skin breakdown ✘
o Skin irritation or pressure injuries can trigger autonomic dysreflexia. However,
this assessment comes after immediate measures to reduce blood pressure.
• C. Check the client's bladder for distention ✘
o Bladder distention is the most common cause of autonomic dysreflexia, but the
nurse should first position the client upright to lower blood pressure before
investigating the cause.
• D. Place the client in a sitting position ✔
o This is the priority intervention. Sitting the client upright promotes pooling of
blood in the lower extremities, helping reduce severe hypertension and lowering
the risk of stroke or seizure.
NCLEX/ATI Exam Tip
Remember the sequence:
1. Sit the client upright immediately.
2. Loosen restrictive clothing.
3. Check the bladder (kinked catheter, urinary retention).
4. Check for bowel impaction.
, 5. Assess for other noxious stimuli (pressure areas, tight clothing, ingrown toenails).
Memory Trick: "Sit Before You Search."
Question 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
Correct Answers: A, C, E
Rationale
• A. Poor nutritional state ✔
o Protein, vitamin C, and zinc deficiencies delay wound healing and increase the
risk of wound separation (dehiscence).
• B. Altered mental status ✘
o Although altered mental status may affect a client's ability to follow instructions,
it is not a direct risk factor for wound dehiscence.
• C. Obesity ✔
o Excess adipose tissue has a poorer blood supply, increasing tension on the
incision and delaying healing.
• D. Pain medication administration ✘
o Pain medications help clients move comfortably and cough effectively. They do
not increase the risk of dehiscence.
• E. Wound infection ✔
o Infection weakens tissue integrity, making wound separation much more likely.
NCLEX/ATI Exam Tip
QUESTIONS AND ALL CORRECT
ANSWERS 100% SOLVED AND
GUARANTEED SUCCESS!!
Question 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
Correct Answer(s): A, C, D
Rationale:
• A. Dyspnea – Indicates pulmonary congestion caused by fluid overload.
• B. Gastrointestinal bloating ✘ – Not a classic manifestation of fluid volume overload
during blood transfusion.
• C. Jugular vein distention – Elevated venous pressure causes neck vein distention, a
hallmark of fluid overload.
• D. Confusion – Reduced oxygenation from pulmonary edema can lead to altered
mental status.
• E. Hypotension ✘ – Fluid overload more commonly causes hypertension rather than
hypotension.
Exam Tip: During blood transfusions, monitor clients with heart failure closely for TACO
(Transfusion-Associated Circulatory Overload). Early signs include dyspnea, JVD, crackles,
hypertension, and confusion.
,Question 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.
Correct Answer: D. Place the client in a sitting position
Rationale
• A. Check the client for a fecal impaction ✘
o Fecal impaction is a common trigger of autonomic dysreflexia, but it is not the
first action. The nurse should first reduce the dangerously high blood pressure.
• B. Examine the client for areas of skin breakdown ✘
o Skin irritation or pressure injuries can trigger autonomic dysreflexia. However,
this assessment comes after immediate measures to reduce blood pressure.
• C. Check the client's bladder for distention ✘
o Bladder distention is the most common cause of autonomic dysreflexia, but the
nurse should first position the client upright to lower blood pressure before
investigating the cause.
• D. Place the client in a sitting position ✔
o This is the priority intervention. Sitting the client upright promotes pooling of
blood in the lower extremities, helping reduce severe hypertension and lowering
the risk of stroke or seizure.
NCLEX/ATI Exam Tip
Remember the sequence:
1. Sit the client upright immediately.
2. Loosen restrictive clothing.
3. Check the bladder (kinked catheter, urinary retention).
4. Check for bowel impaction.
, 5. Assess for other noxious stimuli (pressure areas, tight clothing, ingrown toenails).
Memory Trick: "Sit Before You Search."
Question 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
Correct Answers: A, C, E
Rationale
• A. Poor nutritional state ✔
o Protein, vitamin C, and zinc deficiencies delay wound healing and increase the
risk of wound separation (dehiscence).
• B. Altered mental status ✘
o Although altered mental status may affect a client's ability to follow instructions,
it is not a direct risk factor for wound dehiscence.
• C. Obesity ✔
o Excess adipose tissue has a poorer blood supply, increasing tension on the
incision and delaying healing.
• D. Pain medication administration ✘
o Pain medications help clients move comfortably and cough effectively. They do
not increase the risk of dehiscence.
• E. Wound infection ✔
o Infection weakens tissue integrity, making wound separation much more likely.
NCLEX/ATI Exam Tip
