MEDSURG VATI ASSESSMENT 90 Q'S QUESTIONS
WITH SOLUTIONS
A nurse is assisting with the care of four clients. Which of the following clients is the priority for
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the nurse to see ,i . ,i. ,i.
-A client who has chest tubes and an oxygen Sat of 90%
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- aclient who has peripheral edema and urinary output of 130 over 4hrs
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- A client who has a permanent pacemaker with heart rate of 76/min
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-a client who has pericarditis and temp. 38 c 100.4 - answers- A client who has chest tubes and an oxygen Sat of 90%
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Using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding is
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the client's oxygen saturation level, which is below the expected reference range of 95% to 100%. Therefore, the nurse
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should attend to this client first.
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A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3. Which
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of the following findings should the nurse expect?
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- Vacalizes sound
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-Blinks eyes when asked ,i. ,i. ,i.
-Follows motor commands ,i . ,i.
-Nonresponsive Commands - answersNonresponsive Commands ,i. ,i . ,i . ,i .
A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose state. The GCS is a
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standardized tool that allows for the evaluation of a client's level of consciousness. The test is divided into three sections
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that evaluate eye opening, motor response, and verbal response. The GCS ranges from a high score of 15 (fully alert) to a
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low score of 3 (fully comatose).
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A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a closed chest drainage system
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connected to low suction. For which of the following findings should the nurse notify the charge nurse
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- Fluctation of the water level in the water seal chamber
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-constant bubling in the suction control chamber ,i. ,i . ,i . ,i . , i. ,i.
- periodic bubbling in the water seal chamber
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- Persistent bubbling in the water seal chamber - answers- Persistent bubbling in the water seal chamber
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Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the drainage system. The nurse ,i. ,i . ,i. ,i. ,i. , i. ,i. ,i . ,i . ,i . ,i . ,i. , i. ,i . ,i. ,i. ,i.
should notify the charge nurse of this finding.
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A nurse is reinforcing teaching with a male client who has right sided hemiparesis about
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preforming ADL's. Which of the following instructions should the nurse include in the teaching ,i. ,i. ,i. ,i. ,i. ,i. ,i . ,i . ,i. ,i . ,i. ,i. ,i.
-Comb your hair with the unaffected arm ,i. ,i. ,i . ,i . ,i. ,i .
-Dress your unaffected side first , i. , i. ,i. ,i .
choose clothing with buttons ,i . ,i . ,i .
-shave with your affected side - answersComb your hair with the unaffected arm,i. ,i. ,i. ,i. ,i. ,i . ,i. ,i. ,i . ,i . ,i. ,i .
1/13 ,i. ,i.
,The nurse should instruct the client to brush their hair with the unaffected arm to reduce frustration and increase
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independence and self-esteem.
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A nurse is collecting data from a client and auscultates intermittent high-pitched sounds during inspiration over the lower
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base of the lungs. The nurse should identify this finding as which of the following lungs sounds
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- Fine crackles
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-stridor
-rhonchi
-friction - answers- Fine crackles , i. ,i. , i. , i.
Fine crackles are auscultated in the base of the lungs as air moves through airway secretions. Fine crackles are
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intermittent, high-pitched sounds heard more often during inspiration.
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A nurse is collecting data from a client who has coronary artery disease. Which of the following
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manifestations should the nurse identify as an indication that the client has angina ( SatA) ,i. ,i. , i. ,i. ,i . ,i . ,i . ,i. ,i . ,i. ,i . ,i . ,i. ,i.
- Chest Discomfort Radiated
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- Pain lasting less that 15mins
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- Pain that is relieved with rest - answers- Chest Discomfort Radiated
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- Pain lasting less that 15mins
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- Pain that is relieved with res
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A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
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should the nurse plan to see first? ,i. ,i . ,i. ,i . ,i. ,i.
- A client who has diabetes mellitus with diaphoretic - answersA client who has diabetes mellitus with diaphoretic
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When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to atten
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to a client who has diabetes mellitus and is diaphoretic. Diaphoresis is a manifestation of hypoglycemia and can lead to
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decreased cerebral function. The nurse should check the client's blood glucose and administer a fast-acting glucose as
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prescribed.
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A nurse is collecting data from a client who has tuberculosis and started combination therapy
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2months ago. Which of the following diagnostic results indicates that the client is adhering to the ,i. ,i. ,i. ,i . ,i. ,i. ,i. ,i. ,i. ,i . ,i . ,i . ,i. ,i . ,i.
medication regimen. ,i.
- A negative chest X-ray
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- A negative sputum culture
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-A negative tuberculin skin test
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-A negative titer for cytomegalovirus - answersA negative sputum culture
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Tuberculosis is an infectious disease spread through airborne droplets. Sputum cultures are obtained to both diagnose ,i. ,i. ,i. ,i . ,i . ,i. ,i. ,i . , i. ,i. ,i. ,i. ,i . ,i. ,i.
tuberculosis and to determine whether the medication treatment has been effective. After the client begins antibiotic
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treatment for tuberculosis, a sputum culture is obtained monthly. A negative culture is an indication that the client is no
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longer infectious and the medication therapy has been effective.
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A nurse is collecting data from a client who has bacterial meningitis. Which of the following
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findings should the nurse expect? ,i. ,i. ,i . ,i.
- Severe Headache - answers- Severe Headache
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The nurse should expect a client who has meningitis to have severe and persistent headaches that worsen with moveme
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of the head.
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2/13
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WITH SOLUTIONS
A nurse is assisting with the care of four clients. Which of the following clients is the priority for
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the nurse to see ,i . ,i. ,i.
-A client who has chest tubes and an oxygen Sat of 90%
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- aclient who has peripheral edema and urinary output of 130 over 4hrs
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- A client who has a permanent pacemaker with heart rate of 76/min
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-a client who has pericarditis and temp. 38 c 100.4 - answers- A client who has chest tubes and an oxygen Sat of 90%
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Using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding is
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the client's oxygen saturation level, which is below the expected reference range of 95% to 100%. Therefore, the nurse
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should attend to this client first.
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A nurse is collecting data from a client who was admitted with a Glasgow Coma Scale of 3. Which
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of the following findings should the nurse expect?
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- Vacalizes sound
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-Blinks eyes when asked ,i. ,i. ,i.
-Follows motor commands ,i . ,i.
-Nonresponsive Commands - answersNonresponsive Commands ,i. ,i . ,i . ,i .
A client who has a GCS of less than 8 has evidence of severe head injury and is in a comatose state. The GCS is a
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standardized tool that allows for the evaluation of a client's level of consciousness. The test is divided into three sections
,i. ,i . ,i . ,i. ,i. ,i. ,i. ,i . ,i. ,i . ,i . ,i. ,i . ,i. ,i . ,i . ,i. ,i . ,i . ,i .
that evaluate eye opening, motor response, and verbal response. The GCS ranges from a high score of 15 (fully alert) to a
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low score of 3 (fully comatose).
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A nurse is monitoring a client who has a pneumothorax and a chest tube in place with a closed chest drainage system
,i. ,i . ,i. ,i . ,i. ,i . ,i. ,i. ,i . ,i. ,i . ,i . ,i. ,i. ,i. , i. ,i . ,i. ,i. ,i . ,i .
connected to low suction. For which of the following findings should the nurse notify the charge nurse
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- Fluctation of the water level in the water seal chamber
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-constant bubling in the suction control chamber ,i. ,i . ,i . ,i . , i. ,i.
- periodic bubbling in the water seal chamber
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- Persistent bubbling in the water seal chamber - answers- Persistent bubbling in the water seal chamber
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Excessive and persistent bubbling in the water-seal chamber indicates an air leak in the drainage system. The nurse ,i. ,i . ,i. ,i. ,i. , i. ,i. ,i . ,i . ,i . ,i . ,i. , i. ,i . ,i. ,i. ,i.
should notify the charge nurse of this finding.
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A nurse is reinforcing teaching with a male client who has right sided hemiparesis about
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preforming ADL's. Which of the following instructions should the nurse include in the teaching ,i. ,i. ,i. ,i. ,i. ,i. ,i . ,i . ,i. ,i . ,i. ,i. ,i.
-Comb your hair with the unaffected arm ,i. ,i. ,i . ,i . ,i. ,i .
-Dress your unaffected side first , i. , i. ,i. ,i .
choose clothing with buttons ,i . ,i . ,i .
-shave with your affected side - answersComb your hair with the unaffected arm,i. ,i. ,i. ,i. ,i. ,i . ,i. ,i. ,i . ,i . ,i. ,i .
1/13 ,i. ,i.
,The nurse should instruct the client to brush their hair with the unaffected arm to reduce frustration and increase
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independence and self-esteem.
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A nurse is collecting data from a client and auscultates intermittent high-pitched sounds during inspiration over the lower
,i. ,i . ,i. ,i . ,i . ,i. ,i . ,i. ,i . ,i. ,i. ,i . ,i . ,i . ,i . ,i . ,i.
base of the lungs. The nurse should identify this finding as which of the following lungs sounds
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- Fine crackles
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-stridor
-rhonchi
-friction - answers- Fine crackles , i. ,i. , i. , i.
Fine crackles are auscultated in the base of the lungs as air moves through airway secretions. Fine crackles are
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intermittent, high-pitched sounds heard more often during inspiration.
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A nurse is collecting data from a client who has coronary artery disease. Which of the following
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manifestations should the nurse identify as an indication that the client has angina ( SatA) ,i. ,i. , i. ,i. ,i . ,i . ,i . ,i. ,i . ,i. ,i . ,i . ,i. ,i.
- Chest Discomfort Radiated
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- Pain lasting less that 15mins
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- Pain that is relieved with rest - answers- Chest Discomfort Radiated
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- Pain lasting less that 15mins
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- Pain that is relieved with res
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A nurse is receiving change-of-shift report for a group of clients. Which of the following clients
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should the nurse plan to see first? ,i. ,i . ,i. ,i . ,i. ,i.
- A client who has diabetes mellitus with diaphoretic - answersA client who has diabetes mellitus with diaphoretic
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When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is to atten
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to a client who has diabetes mellitus and is diaphoretic. Diaphoresis is a manifestation of hypoglycemia and can lead to
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decreased cerebral function. The nurse should check the client's blood glucose and administer a fast-acting glucose as
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prescribed.
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A nurse is collecting data from a client who has tuberculosis and started combination therapy
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2months ago. Which of the following diagnostic results indicates that the client is adhering to the ,i. ,i. ,i. ,i . ,i. ,i. ,i. ,i. ,i. ,i . ,i . ,i . ,i. ,i . ,i.
medication regimen. ,i.
- A negative chest X-ray
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- A negative sputum culture
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-A negative tuberculin skin test
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-A negative titer for cytomegalovirus - answersA negative sputum culture
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Tuberculosis is an infectious disease spread through airborne droplets. Sputum cultures are obtained to both diagnose ,i. ,i. ,i. ,i . ,i . ,i. ,i. ,i . , i. ,i. ,i. ,i. ,i . ,i. ,i.
tuberculosis and to determine whether the medication treatment has been effective. After the client begins antibiotic
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treatment for tuberculosis, a sputum culture is obtained monthly. A negative culture is an indication that the client is no
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longer infectious and the medication therapy has been effective.
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A nurse is collecting data from a client who has bacterial meningitis. Which of the following
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findings should the nurse expect? ,i. ,i. ,i . ,i.
- Severe Headache - answers- Severe Headache
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The nurse should expect a client who has meningitis to have severe and persistent headaches that worsen with moveme
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of the head.
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2/13
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