PN VATI Medical Surgical Re-evaluation
Assessment
1. Gag reflex: A nurse is caring for a client who just had a endoscopic procedure. Which
of the following is the monitoring priority for this client?
A) Pain
B) Nausea
C) Gag reflex
D) Level of consciousness
2. "You should increase your daily protein intake.": A nurse is reinforcing dis-
charge teaching for a client who has chronic pancreatitis. Which of the following
statements by the nurse is appropriate?
A) "You should decrease your caloric intake when abdominal pain is present."
B) "You should increase your daily protein intake."
C) "You should increase fat intake when experiencing loose stools."
D) "You should limit alcohol intake to 2-2 drinks per week."
3. Administer analgesic medication for incisional pain.
Rationale:
Administer pain medication to establish comfort and then attend to the other
reported condition.: A nurse collects data on a client who returned to the unit four hr ago
following a partial colectomy. Which of the following conditions should the nurse attend to
first?
A) Change the moderately saturated dressing.
B) Administer analgesic medication for incisional pain.
C) Catheterize for a distended bladder.
D) Cough and deep breathe client.
4. Breathing in through the nose and out through pursed lips.: A nurse is reinforcing
discharge teaching on actions that improve gas exchange to a client diagnosed with
emphysema. Which of the following instructions should be included in the teaching?
A) Resting in a supine position
B) Elevating arms while performing ADLs
C) Breathing in through the nose and out through pursed lips.
D) Increasing oxygen delivery to 5 L/min during times of distress.
5. Hard palate: A nurse is assessing a client who is African-American and who is
jaundice. Which of the following areas are the most reliable for the nurse to inspect?
, PN VATI Medical Surgical Re-evaluation
Assessment
A) Palms of hands
B) Hard palate
C) Sclera
D) Nail beds
6. Dried apricots: A nurse is reinforcing teaching with a client who has ulcerative colitis
and requires a low fiber diet. The nurse should instruct the client to avoid which of the
following foods?
A) Cooked carrots
B) Dried apricots
C) Ripe bananas
D) White rice
7. Granulation tissue on the surface of the wound: A nurse is caring for a client who
has a large wound that has a vacuum-assisted closure device placed over it. Which of the
following findings by the nurse indicated healing of the wound.
A) Granulation tissue on the surface of the wound
B) Musty odor from the foam dressing upon removal
C) Sanguineous drainage in the suction device.
D) Peeling of the edges of the transparent dressing
8. Potassium 2.5 mEq/L: A nurse is caring for a toddler admitted to the hospital with
acute gastroenteritis. Which of the following findings has the highest priority?
A) Weight loss 3% of total body weight.
B) Blood glucose 150 mg/dL
C)Potassium 2.5 mEq/L
D) Urine specific gravity 1.035
9. "Maintain stable blood glucose levels.": A nurse is reinforcing teaching about
preventing long-term complications of retinopathy and neuropathy with an older adult
client who has diabetes mellitus. Which of the following actions is the most important for
the nurse to include in the teaching?
A) "Plan to have an eye examination once per year."
B) "Examine your feet carefully every day".
C) "Wear closed toed shoes daily."
D) "Maintain stable blood glucose levels."
10.Fresh fruit basket: A nurse is reinforcing teaching to the family of a client who has
multiple myeloma and is admitted to the unit with a WBC count of 2,200/mm3. Which of
the following food items brought by the family should the nurse prohibit from being given
to the client?
, PN VATI Medical Surgical Re-evaluation
Assessment
A) Fried chicken
B) Bagels
C) A factory-sealed box of chocolates
D) Fresh fruit basket
11.Sodium 151 mEq/L: A nurse is reviewing the preadmission laboratory test results of a
client who is scheduled for a carotid endarterectomy in 3 days. Which of the following
results should the nurse report to the provider?
A) Sodium 151 mEq/L
B) Chloride 105 mEq/L
C) Potassium 3.8 mEq/L
D) Calcium 9.6 mEq/L
12.Elevate the affected leg: A nurse is caring for a client who has unilateral leg edema
with associated pain and a low-grade temperature. Which of the following action should
the nurse take?
A) Elevate the affected leg
B) Apply cold compresses to the client's leg
C) Place a pillow under the client's knees.
D) Massage the painful area of the leg.
13. -Dehydration
-Oral contraceptive
- Immobility: A nurse is reinforcing teaching with a class about preventing deep-vein
thrombosis. The nurse should include in the teaching that which of the following is a risk
factor for this disorder?
Select all that apply.
- Dehyrdration
- Oral contraceptive use
- Hypertension
- High calcium intake
- Immobility
14.Maintain fluid and electrolyte balance: A nurse is caring for a client who has an
acute exacerbation of ulcerative colitis. The nurse should recognize that which of the
following is the most important nursing action for this client?
A) Preventing skin breakdown
B) Maintain fluid and electrolyte balance
Assessment
1. Gag reflex: A nurse is caring for a client who just had a endoscopic procedure. Which
of the following is the monitoring priority for this client?
A) Pain
B) Nausea
C) Gag reflex
D) Level of consciousness
2. "You should increase your daily protein intake.": A nurse is reinforcing dis-
charge teaching for a client who has chronic pancreatitis. Which of the following
statements by the nurse is appropriate?
A) "You should decrease your caloric intake when abdominal pain is present."
B) "You should increase your daily protein intake."
C) "You should increase fat intake when experiencing loose stools."
D) "You should limit alcohol intake to 2-2 drinks per week."
3. Administer analgesic medication for incisional pain.
Rationale:
Administer pain medication to establish comfort and then attend to the other
reported condition.: A nurse collects data on a client who returned to the unit four hr ago
following a partial colectomy. Which of the following conditions should the nurse attend to
first?
A) Change the moderately saturated dressing.
B) Administer analgesic medication for incisional pain.
C) Catheterize for a distended bladder.
D) Cough and deep breathe client.
4. Breathing in through the nose and out through pursed lips.: A nurse is reinforcing
discharge teaching on actions that improve gas exchange to a client diagnosed with
emphysema. Which of the following instructions should be included in the teaching?
A) Resting in a supine position
B) Elevating arms while performing ADLs
C) Breathing in through the nose and out through pursed lips.
D) Increasing oxygen delivery to 5 L/min during times of distress.
5. Hard palate: A nurse is assessing a client who is African-American and who is
jaundice. Which of the following areas are the most reliable for the nurse to inspect?
, PN VATI Medical Surgical Re-evaluation
Assessment
A) Palms of hands
B) Hard palate
C) Sclera
D) Nail beds
6. Dried apricots: A nurse is reinforcing teaching with a client who has ulcerative colitis
and requires a low fiber diet. The nurse should instruct the client to avoid which of the
following foods?
A) Cooked carrots
B) Dried apricots
C) Ripe bananas
D) White rice
7. Granulation tissue on the surface of the wound: A nurse is caring for a client who
has a large wound that has a vacuum-assisted closure device placed over it. Which of the
following findings by the nurse indicated healing of the wound.
A) Granulation tissue on the surface of the wound
B) Musty odor from the foam dressing upon removal
C) Sanguineous drainage in the suction device.
D) Peeling of the edges of the transparent dressing
8. Potassium 2.5 mEq/L: A nurse is caring for a toddler admitted to the hospital with
acute gastroenteritis. Which of the following findings has the highest priority?
A) Weight loss 3% of total body weight.
B) Blood glucose 150 mg/dL
C)Potassium 2.5 mEq/L
D) Urine specific gravity 1.035
9. "Maintain stable blood glucose levels.": A nurse is reinforcing teaching about
preventing long-term complications of retinopathy and neuropathy with an older adult
client who has diabetes mellitus. Which of the following actions is the most important for
the nurse to include in the teaching?
A) "Plan to have an eye examination once per year."
B) "Examine your feet carefully every day".
C) "Wear closed toed shoes daily."
D) "Maintain stable blood glucose levels."
10.Fresh fruit basket: A nurse is reinforcing teaching to the family of a client who has
multiple myeloma and is admitted to the unit with a WBC count of 2,200/mm3. Which of
the following food items brought by the family should the nurse prohibit from being given
to the client?
, PN VATI Medical Surgical Re-evaluation
Assessment
A) Fried chicken
B) Bagels
C) A factory-sealed box of chocolates
D) Fresh fruit basket
11.Sodium 151 mEq/L: A nurse is reviewing the preadmission laboratory test results of a
client who is scheduled for a carotid endarterectomy in 3 days. Which of the following
results should the nurse report to the provider?
A) Sodium 151 mEq/L
B) Chloride 105 mEq/L
C) Potassium 3.8 mEq/L
D) Calcium 9.6 mEq/L
12.Elevate the affected leg: A nurse is caring for a client who has unilateral leg edema
with associated pain and a low-grade temperature. Which of the following action should
the nurse take?
A) Elevate the affected leg
B) Apply cold compresses to the client's leg
C) Place a pillow under the client's knees.
D) Massage the painful area of the leg.
13. -Dehydration
-Oral contraceptive
- Immobility: A nurse is reinforcing teaching with a class about preventing deep-vein
thrombosis. The nurse should include in the teaching that which of the following is a risk
factor for this disorder?
Select all that apply.
- Dehyrdration
- Oral contraceptive use
- Hypertension
- High calcium intake
- Immobility
14.Maintain fluid and electrolyte balance: A nurse is caring for a client who has an
acute exacerbation of ulcerative colitis. The nurse should recognize that which of the
following is the most important nursing action for this client?
A) Preventing skin breakdown
B) Maintain fluid and electrolyte balance
