VATI Med-Surg Pre and
Post Assessment Exam
2025 Questions and
Correct Answers
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical
ventilation. Which of the following interventions should the nurse take to reduce the
risk for ventilator-associated pneumonia?
A. Position the head of the client's bed in the flat position.
B. Turn the client every 4 hr.
C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
D. Perform hand hygiene prior to suctioning the client's endotracheal tube. CORRECT
ANSWER: C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
The nurse should brush the client's teeth every 8 hr and rinse the client's mouth with an
antimicrobial rinse every 2 hr to reduce the growth of bacteria.
The nurse should elevate the head of the client's bed 30° to reduce the risk for aspiration
and pneumonia. The nurse should turn the client every 2 hr to promote lung expansion
and reduce the risk for pneumonia. The nurse should perform hand hygiene prior to
suctioning the client's endotracheal tube to reduce the risk of introducing bacteria.
A nurse is providing instruction to a new nurse about caring for clients who are
receiving diuretic therapy to treat heart failure. The nurse should explain that which of
the following medications puts clients at risk for both hyperkalemia and hyponatremia?
A. Furosemide
B. Hydrochlorothiazide
C. Metolazone
D. Spironolactone CORRECT ANSWER: D. Spironolactone
Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in the
renal tubules, causing a loss of sodium and water and the retention of potassium. The
possible adverse reactions include hyperkalemia and hyponatremia.
Furosemide is a high-ceiling (loop) diuretic that increases the risk of hyponatremia and
hypokalemia, not hyperkalemia. Hydrochlorothiazide is a thiazide diuretic that
,increases the risk of hypokalemia, not hyperkalemia. Metolazone is a thiazide diuretic
that increases the risk of hyponatremia and hypokalemia, not hyperkalemia.
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the
following findings should the nurse recognize as a risk factor for this medication?
A. History of bulimia
B. History of NSAID use
C. Drinks green tea
D. Has a glass of wine with dinner each day CORRECT ANSWER: B. History of
NSAID use
The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic ulcer
disease. NSAIDs break down the mucosal barrier and cause production of
prostaglandins to decrease, which results in local gastric mucosal injury.
A nurse is planning care for a client following a cardiac catheterization accessed through
his femoral artery. Which of the following actions should the plan to take?
A. Instruct the client to perform range-of-motion exercises to his lower extremities.
B. Perform neurovascular checks with vital signs.
C. Ambulate the client 1 hr following the procedure.
D. Restrict the client's fluid intake. CORRECT ANSWER: B. Perform neurovascular
checks with vital signs.
The nurse should assess color, temperature, and pulse in the affected extremity and
monitor the client for neurovascular changes that can indicate a stroke, such as slurred
speech and visual disturbances.
The client should keep the extremity of the insertion site straight to reduce the risk for
bleeding. A knee brace might be used to restrict movement. The client should remain on
bed rest for 2 to 6 hr following the procedure to reduce the risk for bleeding. The nurse
should increase fluid intake following a cardiac catheterization to promote excretion of
the contrast medium and reduce the risk for dehydration.
A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of
the following laboratory values should indicate to the nurse that the client is effectively
responding to treatment?
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% CORRECT ANSWER: C. Urine specific gravity 1.020
In cases of dehydration or fluid volume deficit, the kidney reabsorbs all available water,
making the urine more concentrated and increasing the urine specific gravity. A level of
, 1.020 is within the expected reference range of 1.005 to 1.030, which indicates that the
treatment is effective.
The nurse is caring for a client with chronic kidney disease.
History of chronic kidney disease (CKD) that has recently progressed to stage 5 with an
eGFR <15. Reports increased edema, shortness of breath with exertion, poor appetite,
and minimal urine output. No known allergies. Discussed need for hemodialysis and
placement of vascular access. Client verbalizes understanding and will be admitted for
arteriovenous (AV) fistula placement and initiation of dialysis. Ultrasound completed
for vein mapping in LUE.
Nurses Notes
Day 1
0922
Client admitted for placement of AV fistula for chronic kidney disease. Consent signed
by surgeon and client. Client verbalizes understanding of procedure. Alert & oriented x
4. Up to chair with minimal assist. Denies pain. Anuric.
Day 1
1202
Started IV fluid 0.45NS at 50mL/hr. Pain level is 0/10. Spouse at bedside.
Laboratory TestResultsReference RangePotassium 5.2 mEq/L3.5 - 5 mEq CORRECT
ANSWER: Anticipated: Weight client daily, Administer sodium polystyrene sulfonate,
and Administer lisinopril
Contraindicated: Administer Potassium chloride, and draw labs from left arm
Draw labs from left arm is contraindicated. The AV fistula is being placed in the left arm.
Therefore, all blood pressure readings, venipunctures, and IV lines should be in the
right arm.
Administer lisinopril is anticipated. ACE inhibitors such as lisinopril are the most
effective to reduce the risk of cardiovascular events in clients with chronic kidney
disease. ACE inhibitors help control blood pressure, which is necessary to preserve
kidney function.
Administer sodium polystyrene sulfonate is anticipated. Sodium polystyrene sulfonate is
a cation exchange resin that is treatment for hyperkalemia.
Administer potassium chloride is contraindicated. Potassium chloride is a supplement
that will increase the potassium level and would negatively impact the client's status.
The client is hyperkalemic and is at risk for adverse effects of this electrolyte imbalance.
Weigh client daily is anticipated. Daily weights at the same time of day, on the same
time of scale, wearing the same amount of clothing is important to monitor for fluid
retention. Clients should also be weighed before and after dialysis for fluid management.
Post Assessment Exam
2025 Questions and
Correct Answers
A nurse is caring for a client who has an endotracheal tube and is receiving mechanical
ventilation. Which of the following interventions should the nurse take to reduce the
risk for ventilator-associated pneumonia?
A. Position the head of the client's bed in the flat position.
B. Turn the client every 4 hr.
C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
D. Perform hand hygiene prior to suctioning the client's endotracheal tube. CORRECT
ANSWER: C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
The nurse should brush the client's teeth every 8 hr and rinse the client's mouth with an
antimicrobial rinse every 2 hr to reduce the growth of bacteria.
The nurse should elevate the head of the client's bed 30° to reduce the risk for aspiration
and pneumonia. The nurse should turn the client every 2 hr to promote lung expansion
and reduce the risk for pneumonia. The nurse should perform hand hygiene prior to
suctioning the client's endotracheal tube to reduce the risk of introducing bacteria.
A nurse is providing instruction to a new nurse about caring for clients who are
receiving diuretic therapy to treat heart failure. The nurse should explain that which of
the following medications puts clients at risk for both hyperkalemia and hyponatremia?
A. Furosemide
B. Hydrochlorothiazide
C. Metolazone
D. Spironolactone CORRECT ANSWER: D. Spironolactone
Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in the
renal tubules, causing a loss of sodium and water and the retention of potassium. The
possible adverse reactions include hyperkalemia and hyponatremia.
Furosemide is a high-ceiling (loop) diuretic that increases the risk of hyponatremia and
hypokalemia, not hyperkalemia. Hydrochlorothiazide is a thiazide diuretic that
,increases the risk of hypokalemia, not hyperkalemia. Metolazone is a thiazide diuretic
that increases the risk of hyponatremia and hypokalemia, not hyperkalemia.
A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the
following findings should the nurse recognize as a risk factor for this medication?
A. History of bulimia
B. History of NSAID use
C. Drinks green tea
D. Has a glass of wine with dinner each day CORRECT ANSWER: B. History of
NSAID use
The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic ulcer
disease. NSAIDs break down the mucosal barrier and cause production of
prostaglandins to decrease, which results in local gastric mucosal injury.
A nurse is planning care for a client following a cardiac catheterization accessed through
his femoral artery. Which of the following actions should the plan to take?
A. Instruct the client to perform range-of-motion exercises to his lower extremities.
B. Perform neurovascular checks with vital signs.
C. Ambulate the client 1 hr following the procedure.
D. Restrict the client's fluid intake. CORRECT ANSWER: B. Perform neurovascular
checks with vital signs.
The nurse should assess color, temperature, and pulse in the affected extremity and
monitor the client for neurovascular changes that can indicate a stroke, such as slurred
speech and visual disturbances.
The client should keep the extremity of the insertion site straight to reduce the risk for
bleeding. A knee brace might be used to restrict movement. The client should remain on
bed rest for 2 to 6 hr following the procedure to reduce the risk for bleeding. The nurse
should increase fluid intake following a cardiac catheterization to promote excretion of
the contrast medium and reduce the risk for dehydration.
A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of
the following laboratory values should indicate to the nurse that the client is effectively
responding to treatment?
A. Sodium 165 mEq/L
B. Potassium 5.2 mEq/L
C. Urine specific gravity 1.020
D. Hct 62% CORRECT ANSWER: C. Urine specific gravity 1.020
In cases of dehydration or fluid volume deficit, the kidney reabsorbs all available water,
making the urine more concentrated and increasing the urine specific gravity. A level of
, 1.020 is within the expected reference range of 1.005 to 1.030, which indicates that the
treatment is effective.
The nurse is caring for a client with chronic kidney disease.
History of chronic kidney disease (CKD) that has recently progressed to stage 5 with an
eGFR <15. Reports increased edema, shortness of breath with exertion, poor appetite,
and minimal urine output. No known allergies. Discussed need for hemodialysis and
placement of vascular access. Client verbalizes understanding and will be admitted for
arteriovenous (AV) fistula placement and initiation of dialysis. Ultrasound completed
for vein mapping in LUE.
Nurses Notes
Day 1
0922
Client admitted for placement of AV fistula for chronic kidney disease. Consent signed
by surgeon and client. Client verbalizes understanding of procedure. Alert & oriented x
4. Up to chair with minimal assist. Denies pain. Anuric.
Day 1
1202
Started IV fluid 0.45NS at 50mL/hr. Pain level is 0/10. Spouse at bedside.
Laboratory TestResultsReference RangePotassium 5.2 mEq/L3.5 - 5 mEq CORRECT
ANSWER: Anticipated: Weight client daily, Administer sodium polystyrene sulfonate,
and Administer lisinopril
Contraindicated: Administer Potassium chloride, and draw labs from left arm
Draw labs from left arm is contraindicated. The AV fistula is being placed in the left arm.
Therefore, all blood pressure readings, venipunctures, and IV lines should be in the
right arm.
Administer lisinopril is anticipated. ACE inhibitors such as lisinopril are the most
effective to reduce the risk of cardiovascular events in clients with chronic kidney
disease. ACE inhibitors help control blood pressure, which is necessary to preserve
kidney function.
Administer sodium polystyrene sulfonate is anticipated. Sodium polystyrene sulfonate is
a cation exchange resin that is treatment for hyperkalemia.
Administer potassium chloride is contraindicated. Potassium chloride is a supplement
that will increase the potassium level and would negatively impact the client's status.
The client is hyperkalemic and is at risk for adverse effects of this electrolyte imbalance.
Weigh client daily is anticipated. Daily weights at the same time of day, on the same
time of scale, wearing the same amount of clothing is important to monitor for fluid
retention. Clients should also be weighed before and after dialysis for fluid management.
