RN VATI Adult Medical Surgical
Assessment Exam Questions with Correct
Verified Answers (Latest 2026/2027 ) –
Guaranteed Pass | Complete Med-Surg
Nursing
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
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. Peripheral edema indicates fluid overload
but is not immediately life-threatening. Mild hypertension is common in heart failure
and is less urgent. 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.
2. A client with left-sided heart failure is being assessed. Which finding should the
nurse identify as a manifestation of left-sided heart failure?
A. Dependent edema in the lower extremities
B. Pink-tinged frothy sputum
C. Jugular vein distention
D. Hepatomegaly
Correct Answer: B
Rationale: Pink-tinged frothy sputum indicates pulmonary edema, a key manifestation
,of left-sided heart failure due to backup of blood into the pulmonary circulation.
Dependent edema, JVD, and hepatomegaly are signs of right-sided heart failure.
3. A nurse is preparing to administer a transfusion of packed RBCs to a client who
has heart failure. For which 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: A, C, D
Rationale: Signs of fluid volume overload include dyspnea (due to pulmonary
congestion), jugular vein distention (due to increased central venous pressure), and
confusion (due to cerebral edema). Gastrointestinal bloating and hypotension are not
primary signs of fluid volume overload.
4. A nurse is reviewing a medication prescription for a patient with type 2 diabetes
undergoing elective surgery. The patient takes metformin 1000 mg twice daily,
insulin glargine 20 units at bedtime, and insulin aspart with meals. Which
prescription should the nurse question?
A. Hold metformin on the morning of surgery
B. Reduce insulin glargine to 50% of the evening dose on the day before surgery
C. Administer insulin aspart at bedtime for sliding scale coverage
D. Start dextrose 5% in 0.45% saline infusion intraoperatively
Correct Answer: C
Rationale: Insulin aspart is a rapid-acting insulin given with meals; using it at bedtime
for sliding scale is inappropriate because it peaks quickly and can cause nocturnal
hypoglycemia. Metformin is held perioperatively to avoid lactic acidosis. Insulin glargine
dose reduction is standard to prevent hypoglycemia during fasting. IV dextrose prevents
hypoglycemia.
5. A nurse on a medical-surgical unit is caring for a group of clients. The nurse
should notify the rapid response team for which client?
,A. Client who has a pressure injury of the right heel whose blood glucose is 300 mg/dL
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac
catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse
Correct Answer: B
Rationale: Right calf pain and shortness of breath are classic signs of a pulmonary
embolism (PE). This client is unstable and requires immediate intervention. The other
findings require assessment but are not immediate emergencies requiring rapid
response team activation.
6. The nurse receives all of the following stat orders for Mr. Palmer. Which one
should the nurse question?
1. Oxygen per nasal cannula at 4 L per minute
2. Enoxaparin (Lovenox) 40 mg subcutaneously
3. Troponin level
4. Computed tomography (CT) angiogram
Correct Answer: 2
Rationale: The nurse should question the order for Lovenox because the patient is
receiving a heparin drip. Both are anticoagulants and concurrent use increases bleeding
risk significantly.
7. A patient on heparin for deep vein thrombosis develops new thrombocytopenia
(platelet count 45,000/L) and a skin lesion at the injection site. Which diagnostic
test would confirm the suspected condition?
A. Platelet factor 4 antibody assay (ELISA)
B. Bleeding time
C. Partial thromboplastin time (aPTT)
D. D-dimer
Correct Answer: A
Rationale: Heparin-induced thrombocytopenia (HIT) is a prothrombotic disorder caused
by antibodies against platelet factor 4/heparin complexes. ELISA detects these
, antibodies and is the confirmatory test. Bleeding time, aPTT, and D-dimer are not
specific for HIT.
8. A client develops sudden chest pain and shortness of breath following hip
replacement surgery. Which complication should the nurse suspect first?
A. Atelectasis
B. Pulmonary embolism
C. Pneumonia
D. Heart failure
Correct Answer: B
Rationale: Classic signs of PE include sudden dyspnea, sharp chest pain, tachycardia,
anxiety, and low oxygen saturation. Orthopedic surgery significantly increases risk for
venous thromboembolism. Immediate interventions include administering oxygen,
notifying the provider, and preparing for diagnostic testing and anticoagulation as
prescribed.
9. A nurse is teaching a client prescribed warfarin. Which statement by the client
indicates understanding?
A. "I'll stop taking the medication when I feel better."
B. "I'll use an electric razor."
C. "I'll avoid all green vegetables."
D. "I'll take aspirin for headaches."
Correct Answer: B
Rationale: Warfarin increases bleeding risk. Safety precautions include using a soft
toothbrush, electric razor, avoiding injury, and reporting bleeding. Clients should never
stop anticoagulants without provider approval. They should maintain a consistent intake
of vitamin K rather than avoiding it completely. Aspirin increases bleeding risk unless
prescribed.
10. A client receiving packed red blood cells suddenly develops chills, fever, and
flank pain. What should the nurse do first?
A. Notify the provider
B. Slow the infusion
Assessment Exam Questions with Correct
Verified Answers (Latest 2026/2027 ) –
Guaranteed Pass | Complete Med-Surg
Nursing
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
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. Peripheral edema indicates fluid overload
but is not immediately life-threatening. Mild hypertension is common in heart failure
and is less urgent. 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.
2. A client with left-sided heart failure is being assessed. Which finding should the
nurse identify as a manifestation of left-sided heart failure?
A. Dependent edema in the lower extremities
B. Pink-tinged frothy sputum
C. Jugular vein distention
D. Hepatomegaly
Correct Answer: B
Rationale: Pink-tinged frothy sputum indicates pulmonary edema, a key manifestation
,of left-sided heart failure due to backup of blood into the pulmonary circulation.
Dependent edema, JVD, and hepatomegaly are signs of right-sided heart failure.
3. A nurse is preparing to administer a transfusion of packed RBCs to a client who
has heart failure. For which 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: A, C, D
Rationale: Signs of fluid volume overload include dyspnea (due to pulmonary
congestion), jugular vein distention (due to increased central venous pressure), and
confusion (due to cerebral edema). Gastrointestinal bloating and hypotension are not
primary signs of fluid volume overload.
4. A nurse is reviewing a medication prescription for a patient with type 2 diabetes
undergoing elective surgery. The patient takes metformin 1000 mg twice daily,
insulin glargine 20 units at bedtime, and insulin aspart with meals. Which
prescription should the nurse question?
A. Hold metformin on the morning of surgery
B. Reduce insulin glargine to 50% of the evening dose on the day before surgery
C. Administer insulin aspart at bedtime for sliding scale coverage
D. Start dextrose 5% in 0.45% saline infusion intraoperatively
Correct Answer: C
Rationale: Insulin aspart is a rapid-acting insulin given with meals; using it at bedtime
for sliding scale is inappropriate because it peaks quickly and can cause nocturnal
hypoglycemia. Metformin is held perioperatively to avoid lactic acidosis. Insulin glargine
dose reduction is standard to prevent hypoglycemia during fasting. IV dextrose prevents
hypoglycemia.
5. A nurse on a medical-surgical unit is caring for a group of clients. The nurse
should notify the rapid response team for which client?
,A. Client who has a pressure injury of the right heel whose blood glucose is 300 mg/dL
B. Client who reports right calf pain and shortness of breath
C. Client who has blood on a pressure dressing in the femoral area following a cardiac
catheterization
D. Client who has dark red coloration of left toes and absent pedal pulse
Correct Answer: B
Rationale: Right calf pain and shortness of breath are classic signs of a pulmonary
embolism (PE). This client is unstable and requires immediate intervention. The other
findings require assessment but are not immediate emergencies requiring rapid
response team activation.
6. The nurse receives all of the following stat orders for Mr. Palmer. Which one
should the nurse question?
1. Oxygen per nasal cannula at 4 L per minute
2. Enoxaparin (Lovenox) 40 mg subcutaneously
3. Troponin level
4. Computed tomography (CT) angiogram
Correct Answer: 2
Rationale: The nurse should question the order for Lovenox because the patient is
receiving a heparin drip. Both are anticoagulants and concurrent use increases bleeding
risk significantly.
7. A patient on heparin for deep vein thrombosis develops new thrombocytopenia
(platelet count 45,000/L) and a skin lesion at the injection site. Which diagnostic
test would confirm the suspected condition?
A. Platelet factor 4 antibody assay (ELISA)
B. Bleeding time
C. Partial thromboplastin time (aPTT)
D. D-dimer
Correct Answer: A
Rationale: Heparin-induced thrombocytopenia (HIT) is a prothrombotic disorder caused
by antibodies against platelet factor 4/heparin complexes. ELISA detects these
, antibodies and is the confirmatory test. Bleeding time, aPTT, and D-dimer are not
specific for HIT.
8. A client develops sudden chest pain and shortness of breath following hip
replacement surgery. Which complication should the nurse suspect first?
A. Atelectasis
B. Pulmonary embolism
C. Pneumonia
D. Heart failure
Correct Answer: B
Rationale: Classic signs of PE include sudden dyspnea, sharp chest pain, tachycardia,
anxiety, and low oxygen saturation. Orthopedic surgery significantly increases risk for
venous thromboembolism. Immediate interventions include administering oxygen,
notifying the provider, and preparing for diagnostic testing and anticoagulation as
prescribed.
9. A nurse is teaching a client prescribed warfarin. Which statement by the client
indicates understanding?
A. "I'll stop taking the medication when I feel better."
B. "I'll use an electric razor."
C. "I'll avoid all green vegetables."
D. "I'll take aspirin for headaches."
Correct Answer: B
Rationale: Warfarin increases bleeding risk. Safety precautions include using a soft
toothbrush, electric razor, avoiding injury, and reporting bleeding. Clients should never
stop anticoagulants without provider approval. They should maintain a consistent intake
of vitamin K rather than avoiding it completely. Aspirin increases bleeding risk unless
prescribed.
10. A client receiving packed red blood cells suddenly develops chills, fever, and
flank pain. What should the nurse do first?
A. Notify the provider
B. Slow the infusion
