RN VATI Adult Medical Surgical
2019(Score 100%) Download to
score A
Question 1
A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal
bleeding. Which of the following actions should the nurse take first?
A. Administer vasopressin IV
B. Request blood from the blood bank
C. Verify that the client has adequate IV access
D. Insert an indwelling urinary catheter
Correct Answer: C
Rationale: The nurse must first verify adequate IV access before any interventions can be
effectively implemented. Vasopressin (A) may be necessary but requires IV access. Blood
products (B) also require patent IV access. Urinary catheter insertion (D) is not the priority
during active hemorrhage with hypotension.
Question 2
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse identify as a manifestation of left-sided heart failure?
A. Dependent edema
B. Jugular vein distention
C. Weight gain
D. Frothy sputum and dyspnea
Correct Answer: D
,Rationale: Frothy sputum, dyspnea, and wheezing are manifestations of left-sided heart failure
due to pulmonary congestion. Dependent edema (A), JVD (B), and weight gain (C) are
manifestations of right-sided heart failure.
Question 3
A nurse is caring for a client who is receiving a transfusion of packed RBCs. The client's blood
type is AB positive and the blood infusing is labeled type B negative. Which of the following
actions should the nurse take?
A. Stop the transfusion immediately
B. Monitor the client for any adverse reactions
C. Administer a diuretic prophylactically
D. Notify the blood bank of the discrepancy
Correct Answer: B
Rationale: The client with AB positive blood is a universal recipient and can receive any ABO
blood type. The nurse should continue to monitor for adverse reactions as with any transfusion.
Stopping the transfusion (A) is not indicated. Diuretics (C) are not routine. Notification (D) is
unnecessary since this is an acceptable match.
Question 4
A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following
findings should the nurse identify as a manifestation of cardiac tamponade?
A. Paradoxical pulse
B. Bradycardia
C. Hypertension
D. Muffled bowel sounds
Correct Answer: A
Rationale: Cardiac tamponade causes a paradoxical pulse (systolic BP drop >10 mm Hg on
inspiration). Bradycardia (B) and hypertension (C) are not typical; tachycardia and hypotension
are expected. Muffled bowel sounds (D) are unrelated.
Question 5
,A nurse is teaching a client who has cholelithiasis about dietary modifications. Which of the
following statements should the nurse include?
A. "Cauliflower is a good dietary choice."
B. "Increase the amount of egg yolks in your diet."
C. "Select desserts such as angel-food cake."
D. "Eat choice or prime cuts of meat."
Correct Answer: C
Rationale: Angel-food cake is low in fat and cholesterol, making it a suitable choice for clients
with gallstones. Cauliflower (A) may exacerbate symptoms. Egg yolks (B) are high in cholesterol.
Prime cuts (D) are high in fat, which can trigger gallbladder symptoms.
Question 6
A nurse is caring for a client who has deep vein thrombosis and is receiving heparin via
continuous IV infusion. The client's aPTT is 95 seconds. Using a standard heparin titration
protocol, which of the following actions should the nurse take?
A. Increase the infusion rate
B. Maintain the current infusion rate
C. Stop the infusion for 1 hour, then restart at a decreased rate
D. Administer protamine sulfate immediately
Correct Answer: C
Rationale: For aPTT >95 seconds on a standard protocol, the nurse should stop the infusion for
1 hour, then restart at a decreased rate. Increasing (A) or maintaining (B) would increase
bleeding risk. Protamine sulfate (D) is reserved for severe bleeding or overdose.
Question 7
A nurse is assessing a client who is receiving vancomycin IV for MRSA. Which of the following
findings indicates the client is experiencing an adverse effect of the medication?
A. Elevated blood pressure
B. Flushing of the face and upper body
C. Bradycardia
D. Increased urine output
, Correct Answer: B
Rationale: Flushing, rash on the face and upper body (red man syndrome), and hypotension
result from infusing vancomycin too rapidly. The nurse should infuse over at least 60 minutes.
Elevated BP (A), bradycardia (C), and increased urine output (D) are not associated with
vancomycin infusion reaction.
Question 8
A nurse is reviewing laboratory findings for a client who has Cushing's syndrome. Which of the
following findings should the nurse expect?
A. Hypokalemia
B. Hyperkalemia
C. Hypoglycemia
D. Decreased cortisol level
Correct Answer: A
Rationale: Cushing's syndrome causes increased aldosterone production, leading to sodium
retention, fluid retention, and hypokalemia. Hyperkalemia (B) is associated with Addison's
disease. Hyperglycemia (not hypoglycemia) is expected. Cortisol levels are elevated, not
decreased (D).
Question 9
A nurse is inspecting the skin of a client who has basal cell carcinoma. Which of the following
lesion characteristics should the nurse expect?
A. A pearly, waxy nodule
B. An irregular border on a variegated-colored lesion
C. A firm, nodular, crusty, or ulcerated lesion
D. A flat, scaly, reddish patch
Correct Answer: A
Rationale: Basal cell carcinoma presents as a nodular lesion with well-defined borders and a
pearly or waxy appearance, typically on sun-exposed areas. Irregular borders with variegated
colors (B) indicate melanoma. Firm, crusty lesions (C) suggest squamous cell carcinoma. Flat,
scaly patches (D) may indicate actinic keratosis.
2019(Score 100%) Download to
score A
Question 1
A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal
bleeding. Which of the following actions should the nurse take first?
A. Administer vasopressin IV
B. Request blood from the blood bank
C. Verify that the client has adequate IV access
D. Insert an indwelling urinary catheter
Correct Answer: C
Rationale: The nurse must first verify adequate IV access before any interventions can be
effectively implemented. Vasopressin (A) may be necessary but requires IV access. Blood
products (B) also require patent IV access. Urinary catheter insertion (D) is not the priority
during active hemorrhage with hypotension.
Question 2
A nurse is assessing a client who has left-sided heart failure. Which of the following findings
should the nurse identify as a manifestation of left-sided heart failure?
A. Dependent edema
B. Jugular vein distention
C. Weight gain
D. Frothy sputum and dyspnea
Correct Answer: D
,Rationale: Frothy sputum, dyspnea, and wheezing are manifestations of left-sided heart failure
due to pulmonary congestion. Dependent edema (A), JVD (B), and weight gain (C) are
manifestations of right-sided heart failure.
Question 3
A nurse is caring for a client who is receiving a transfusion of packed RBCs. The client's blood
type is AB positive and the blood infusing is labeled type B negative. Which of the following
actions should the nurse take?
A. Stop the transfusion immediately
B. Monitor the client for any adverse reactions
C. Administer a diuretic prophylactically
D. Notify the blood bank of the discrepancy
Correct Answer: B
Rationale: The client with AB positive blood is a universal recipient and can receive any ABO
blood type. The nurse should continue to monitor for adverse reactions as with any transfusion.
Stopping the transfusion (A) is not indicated. Diuretics (C) are not routine. Notification (D) is
unnecessary since this is an acceptable match.
Question 4
A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following
findings should the nurse identify as a manifestation of cardiac tamponade?
A. Paradoxical pulse
B. Bradycardia
C. Hypertension
D. Muffled bowel sounds
Correct Answer: A
Rationale: Cardiac tamponade causes a paradoxical pulse (systolic BP drop >10 mm Hg on
inspiration). Bradycardia (B) and hypertension (C) are not typical; tachycardia and hypotension
are expected. Muffled bowel sounds (D) are unrelated.
Question 5
,A nurse is teaching a client who has cholelithiasis about dietary modifications. Which of the
following statements should the nurse include?
A. "Cauliflower is a good dietary choice."
B. "Increase the amount of egg yolks in your diet."
C. "Select desserts such as angel-food cake."
D. "Eat choice or prime cuts of meat."
Correct Answer: C
Rationale: Angel-food cake is low in fat and cholesterol, making it a suitable choice for clients
with gallstones. Cauliflower (A) may exacerbate symptoms. Egg yolks (B) are high in cholesterol.
Prime cuts (D) are high in fat, which can trigger gallbladder symptoms.
Question 6
A nurse is caring for a client who has deep vein thrombosis and is receiving heparin via
continuous IV infusion. The client's aPTT is 95 seconds. Using a standard heparin titration
protocol, which of the following actions should the nurse take?
A. Increase the infusion rate
B. Maintain the current infusion rate
C. Stop the infusion for 1 hour, then restart at a decreased rate
D. Administer protamine sulfate immediately
Correct Answer: C
Rationale: For aPTT >95 seconds on a standard protocol, the nurse should stop the infusion for
1 hour, then restart at a decreased rate. Increasing (A) or maintaining (B) would increase
bleeding risk. Protamine sulfate (D) is reserved for severe bleeding or overdose.
Question 7
A nurse is assessing a client who is receiving vancomycin IV for MRSA. Which of the following
findings indicates the client is experiencing an adverse effect of the medication?
A. Elevated blood pressure
B. Flushing of the face and upper body
C. Bradycardia
D. Increased urine output
, Correct Answer: B
Rationale: Flushing, rash on the face and upper body (red man syndrome), and hypotension
result from infusing vancomycin too rapidly. The nurse should infuse over at least 60 minutes.
Elevated BP (A), bradycardia (C), and increased urine output (D) are not associated with
vancomycin infusion reaction.
Question 8
A nurse is reviewing laboratory findings for a client who has Cushing's syndrome. Which of the
following findings should the nurse expect?
A. Hypokalemia
B. Hyperkalemia
C. Hypoglycemia
D. Decreased cortisol level
Correct Answer: A
Rationale: Cushing's syndrome causes increased aldosterone production, leading to sodium
retention, fluid retention, and hypokalemia. Hyperkalemia (B) is associated with Addison's
disease. Hyperglycemia (not hypoglycemia) is expected. Cortisol levels are elevated, not
decreased (D).
Question 9
A nurse is inspecting the skin of a client who has basal cell carcinoma. Which of the following
lesion characteristics should the nurse expect?
A. A pearly, waxy nodule
B. An irregular border on a variegated-colored lesion
C. A firm, nodular, crusty, or ulcerated lesion
D. A flat, scaly, reddish patch
Correct Answer: A
Rationale: Basal cell carcinoma presents as a nodular lesion with well-defined borders and a
pearly or waxy appearance, typically on sun-exposed areas. Irregular borders with variegated
colors (B) indicate melanoma. Firm, crusty lesions (C) suggest squamous cell carcinoma. Flat,
scaly patches (D) may indicate actinic keratosis.
