MEDSURG VATI ASSESSMENT 90 Q'S
WITH ANSWERS (100% CORRECT
ANSWERS)
Question 1
A nurse is assisting with the care of four clients. Which of the following clients is the priority
for the nurse to see?
• A client who has chest tubes and an oxygen saturation of 90%
• A client who has peripheral edema and urinary output of 130 mL over 4 hr
• A client who has a permanent pacemaker with a heart rate of 76/min
• A client who has pericarditis and a temperature of 38°C (100.4°F)
Correct Answer:
A client who has chest tubes and an oxygen saturation of 90%.
Rationale:
Using the Airway, Breathing, and Circulation (ABC) priority framework, impaired oxygenation is
the most urgent finding. An oxygen saturation of 90% is below the expected range of 95%–100%
and indicates hypoxemia. The client requires immediate assessment and intervention to
improve oxygenation.
Exam Tip
Whenever oxygenation, airway, or breathing is compromised, ABCs always take priority over
circulation, fever, or chronic conditions.
Priority Strategy: ABCs (Breathing)
Question 2
,A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale (GCS)
score of 3. Which of the following findings should the nurse expect?
• Vocalizes sounds
• Blinks eyes when asked
• Follows motor commands
• Nonresponsive to commands
Correct Answer:
Nonresponsive to commands
Rationale:
A Glasgow Coma Scale score of 3 is the lowest possible score and indicates deep coma with
severe neurological impairment. The client demonstrates:
• No eye opening
• No verbal response
• No motor response
The client will therefore be nonresponsive to commands.
Remember the GCS
Score Interpretation
15 Fully alert
13–14 Mild impairment
9–12 Moderate injury
≤8 Severe brain injury/coma
3 Deep coma (lowest possible score)
Exam Tip
GCS ≤ 8 = Prepare to protect the airway.
Priority Strategy: ABCs + Neurological Assessment
,Question 3
A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a
closed chest drainage system connected to low suction. Which finding should the nurse notify
the charge nurse about?
• Fluctuation of the water level in the water-seal chamber
• Constant bubbling in the suction-control chamber
• Periodic bubbling in the water-seal chamber
• Persistent bubbling in the water-seal chamber
Correct Answer:
Persistent bubbling in the water-seal chamber
Rationale:
Persistent bubbling in the water-seal chamber indicates an air leak somewhere in the chest
drainage system or the client. Air leaks interfere with proper lung re-expansion and require
immediate assessment.
Normal findings include:
• ✔ Tidaling (fluctuation) in the water-seal chamber
• ✔ Gentle bubbling in the suction-control chamber (when wet suction is used)
Chest Tube Pearls
Finding Interpretation
Tidaling Normal
Gentle bubbling in suction chamber Normal
Persistent bubbling in water seal Air leak
No tidaling after lung expansion May be normal
Priority Strategy: Safety + Breathing (ABC)
, Question 4
A nurse is reinforcing teaching with a male client who has right-sided hemiparesis about
performing activities of daily living (ADLs). Which instruction should the nurse include?
• Comb your hair with the unaffected arm.
• Dress your unaffected side first.
• Choose clothing with buttons.
• Shave with your affected side.
Correct Answer:
Comb your hair with the unaffected arm.
Rationale:
Clients with hemiparesis should use their unaffected extremity when performing ADLs to
maximize independence and decrease frustration.
Teaching points include:
• Dress the affected side first (not the unaffected side).
• Undress the unaffected side first.
• Choose clothing with Velcro or elastic, not buttons.
• Perform grooming using the unaffected arm whenever possible.
Exam Tip
Remember:
Dress the weak side FIRST.
Undress the strong side FIRST.
Priority Strategy: Promoting Independence & Safety
Question 5
A nurse is collecting data from a client and auscultates intermittent high-pitched sounds
during inspiration over the lower bases of the lungs. The nurse should identify this finding as
which of the following lung sounds?
WITH ANSWERS (100% CORRECT
ANSWERS)
Question 1
A nurse is assisting with the care of four clients. Which of the following clients is the priority
for the nurse to see?
• A client who has chest tubes and an oxygen saturation of 90%
• A client who has peripheral edema and urinary output of 130 mL over 4 hr
• A client who has a permanent pacemaker with a heart rate of 76/min
• A client who has pericarditis and a temperature of 38°C (100.4°F)
Correct Answer:
A client who has chest tubes and an oxygen saturation of 90%.
Rationale:
Using the Airway, Breathing, and Circulation (ABC) priority framework, impaired oxygenation is
the most urgent finding. An oxygen saturation of 90% is below the expected range of 95%–100%
and indicates hypoxemia. The client requires immediate assessment and intervention to
improve oxygenation.
Exam Tip
Whenever oxygenation, airway, or breathing is compromised, ABCs always take priority over
circulation, fever, or chronic conditions.
Priority Strategy: ABCs (Breathing)
Question 2
,A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale (GCS)
score of 3. Which of the following findings should the nurse expect?
• Vocalizes sounds
• Blinks eyes when asked
• Follows motor commands
• Nonresponsive to commands
Correct Answer:
Nonresponsive to commands
Rationale:
A Glasgow Coma Scale score of 3 is the lowest possible score and indicates deep coma with
severe neurological impairment. The client demonstrates:
• No eye opening
• No verbal response
• No motor response
The client will therefore be nonresponsive to commands.
Remember the GCS
Score Interpretation
15 Fully alert
13–14 Mild impairment
9–12 Moderate injury
≤8 Severe brain injury/coma
3 Deep coma (lowest possible score)
Exam Tip
GCS ≤ 8 = Prepare to protect the airway.
Priority Strategy: ABCs + Neurological Assessment
,Question 3
A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a
closed chest drainage system connected to low suction. Which finding should the nurse notify
the charge nurse about?
• Fluctuation of the water level in the water-seal chamber
• Constant bubbling in the suction-control chamber
• Periodic bubbling in the water-seal chamber
• Persistent bubbling in the water-seal chamber
Correct Answer:
Persistent bubbling in the water-seal chamber
Rationale:
Persistent bubbling in the water-seal chamber indicates an air leak somewhere in the chest
drainage system or the client. Air leaks interfere with proper lung re-expansion and require
immediate assessment.
Normal findings include:
• ✔ Tidaling (fluctuation) in the water-seal chamber
• ✔ Gentle bubbling in the suction-control chamber (when wet suction is used)
Chest Tube Pearls
Finding Interpretation
Tidaling Normal
Gentle bubbling in suction chamber Normal
Persistent bubbling in water seal Air leak
No tidaling after lung expansion May be normal
Priority Strategy: Safety + Breathing (ABC)
, Question 4
A nurse is reinforcing teaching with a male client who has right-sided hemiparesis about
performing activities of daily living (ADLs). Which instruction should the nurse include?
• Comb your hair with the unaffected arm.
• Dress your unaffected side first.
• Choose clothing with buttons.
• Shave with your affected side.
Correct Answer:
Comb your hair with the unaffected arm.
Rationale:
Clients with hemiparesis should use their unaffected extremity when performing ADLs to
maximize independence and decrease frustration.
Teaching points include:
• Dress the affected side first (not the unaffected side).
• Undress the unaffected side first.
• Choose clothing with Velcro or elastic, not buttons.
• Perform grooming using the unaffected arm whenever possible.
Exam Tip
Remember:
Dress the weak side FIRST.
Undress the strong side FIRST.
Priority Strategy: Promoting Independence & Safety
Question 5
A nurse is collecting data from a client and auscultates intermittent high-pitched sounds
during inspiration over the lower bases of the lungs. The nurse should identify this finding as
which of the following lung sounds?
