MEDSURG VATI ASSESSMENT 90 QUESTIONS AND ANSWERS

MEDSURG VATI ASSESSMENT 90
QUESTIONS AND ANSWERS

Avnnursevnisvnassistingvnwithvnthevncarevnofvnfourvnclients.vnWhichvnofvnthevnfollowingvnclient
svnisvnthevnpriorityvnfor
thevnnursevntovnsee

-AvnclientvnwhovnhasvnchestvntubesvnandvnanvnoxygenvnSatvnofvn90%
-vnaclientvnwhovnhasvnperipheralvnedemavnandvnurinaryvnoutputvnofvn130vnovervn4hrs
-vnAvnclientvnwhovnhasvnavnpermanentvnpacemakervnwithvnheartvnratevnofvn76/min
-avnclientvnwhovnhasvnpericarditisvnandvntemp.vn38vncvn100.4vn-vnanswer---
vnAvnclientvnwhovnhasvnchestvntubesvnandvnanvnoxygenvnSatvnofvn90%



Usingvnthevnairway,vnbreathing,vnandvncirculationvnapproachvntovnclientvncare,vnthevnnursevn
shouldvndeterminevnthatvnthevnpriorityvnfindingvnisvnthevnclient'svnoxygenvnsaturationvnlevel,v
nwhichvnisvnbelowvnthevnexpectedvnreferencevnrangevnofvn95%vntovn100%.vnTherefore,vnthev

nnursevnshouldvnattendvntovnthisvnclientvnfirst.



AvnnursevnisvncollectingvndatavnfromvnavnclientvnwhovnwasvnadmittedvnwithvnavnGlasgowvnCo
mavnScalevnofvn3.vnWhich
ofvnthevnfollowingvnfindingsvnshouldvnthevnnursevnexpect?
-vnVacalizesvnsound
-Blinksvneyesvnwhenvnasked
-Followsvnmotorvncommands
-NonresponsivevnCommandsvn-vnanswer--NonresponsivevnCommands

AvnclientvnwhovnhasvnavnGCSvnofvnlessvnthanvn8vnhasvnevidencevnofvnseverevnheadvninjuryvna
ndvnisvninvnavncomatosevnstate.vnThevnGCSvnisvnavnstandardizedvntoolvnthatvnallowsvnforvnthe
vnevaluationvnofvnavnclient'svnlevelvnofvnconsciousness.vnThevntestvnisvndividedvnintovnthreevn

sectionsvnthatvnevaluatevneyevnopening,vnmotorvnresponse,vnandvnverbalvnresponse.vnThev
nGCSvnrangesvnfromvnavnhighvnscorevnofvn15vn(fullyvnalert)vntovnavnlowvnscorevnofvn3vn(fullyvnc

omatose).

Avnnursevnisvnmonitoringvnavnclientvnwhovnhasvnavnpneumothoraxvnandvnavnchestvntubevninvn
placevnwithvnavnclosedvnchestvndrainagevnsystemvnconnectedvntovnlowvnsuction.vnForvnwhic
hvnofvnthevnfollowingvnfindingsvnshouldvnthevnnursevnnotifyvnthevnchargevnnurse

-vnFluctationvnofvnthevnwatervnlevelvninvnthevnwatervnsealvnchamber
-constantvnbublingvninvnthevnsuctionvncontrolvnchamber
-vnperiodicvnbubblingvninvnthevnwatervnsealvnchamber
-vnPersistentvnbubblingvninvnthevnwatervnsealvnchambervn-vnanswer---
vnPersistentvnbubblingvninvnthevnwatervnsealvnchamber



Excessivevnandvnpersistentvnbubblingvninvnthevnwater-
sealvnchambervnindicatesvnanvnairvnleakvninvnthevndrainagevnsystem.vnThevnnursevnshouldvn
notifyvnthevnchargevnnursevnofvnthisvnfinding.

,Avnnursevnisvnreinforcingvnteachingvnwithvnavnmalevnclientvnwhovnhasvnrightvnsidedvnhemipar
esisvnabout
preformingvnADL's.vnWhichvnofvnthevnfollowingvninstructionsvnshouldvnthevnnursevnincludevn
invnthevnteaching
-Combvnyourvnhairvnwithvnthevnunaffectedvnarm
-Dressvnyourvnunaffectedvnsidevnfirst
choosevnclothingvnwithvnbuttons
-shavevnwithvnyourvnaffectedvnsidevn-vnanswer--
Combvnyourvnhairvnwithvnthevnunaffectedvnarm

Thevnnursevnshouldvninstructvnthevnclientvntovnbrushvntheirvnhairvnwithvnthevnunaffectedvnarm
vntovnreducevnfrustrationvnandvnincreasevnindependencevnandvnself-esteem.



Avnnursevnisvncollectingvndatavnfromvnavnclientvnandvnauscultatesvnintermittentvnhigh-
pitchedvnsoundsvnduringvninspirationvnovervnthevnlowervnbasevnofvnthevnlungs.vnThevnnursev
nshouldvnidentifyvnthisvnfindingvnasvnwhichvnofvnthevnfollowingvnlungsvnsounds



-vnFinevncrackles
-stridor
-rhonchi
-frictionvn-vnanswer---vnFinevncrackles

Finevncracklesvnarevnauscultatedvninvnthevnbasevnofvnthevnlungsvnasvnairvnmovesvnthroughvna
irwayvnsecretions.vnFinevncracklesvnarevnintermittent,vnhigh-
pitchedvnsoundsvnheardvnmorevnoftenvnduringvninspiration.

Avnnursevnisvncollectingvndatavnfromvnavnclientvnwhovnhasvncoronaryvnarteryvndisease.vnWhi
chvnofvnthevnfollowing
manifestationsvnshouldvnthevnnursevnidentifyvnasvnanvnindicationvnthatvnthevnclientvnhasvnan
ginavn(vnSatA)
-vnChestvnDiscomfortvnRadiated
-vnPainvnlastingvnlessvnthatvn15mins
-vnPainvnthatvnisvnrelievedvnwithvnrestvn-vnanswer---vnChestvnDiscomfortvnRadiated
-vnPainvnlastingvnlessvnthatvn15mins
-vnPainvnthatvnisvnrelievedvnwithvnres

Avnnursevnisvnreceivingvnchange-of-
shiftvnreportvnforvnavngroupvnofvnclients.vnWhichvnofvnthevnfollowingvnclients
shouldvnthevnnursevnplanvntovnseevnfirst?
-vnAvnclientvnwhovnhasvndiabetesvnmellitusvnwithvndiaphoreticvn-vnanswer--
Avnclientvnwhovnhasvndiabetesvnmellitusvnwithvndiaphoretic

Whenvnusingvnthevnurgentvnvs.vnnonurgentvnapproachvntovnclientvncare,vnthevnnursevnshoul
dvndeterminevnthatvnthevnpriorityvnactionvnisvntovnattendvntovnavnclientvnwhovnhasvndiabetesvn
mellitusvnandvnisvndiaphoretic.vnDiaphoresisvnisvnavnmanifestationvnofvnhypoglycemiavnand
vncanvnleadvntovndecreasedvncerebralvnfunction.vnThevnnursevnshouldvncheckvnthevnclient'svn

bloodvnglucosevnandvnadministervnavnfast-actingvnglucosevnasvnprescribed.

, Avnnursevnisvnreinforcingvnteachingvnwithvnavnyoungvnadultvnclientvnaboutvntesticularvnself-
examination.vnWhich
ofvnthevnfollowingvninstructionsvnshouldvnthevnnursevninclude?
-vnExaminevnyourvntesticlesvnaftervnavnwarmvnshower
-vnPressvneachvntesticlevninwardlyvnwithvnyourvnfinger
-vnRinsevnanyvnsoapvnoffvnyourvnhandsvnbeforevnexaminingvnyourvntesticle
-Performvnthevnself-vnexaminationvneveryvn2vnmonthvn-vnanswer--
Examinevnyourvntesticlesvnaftervnavnwarmvnshower

Aftervnexposurevntovnwarmvnwatervninvnavnshowervnorvnbath,vnthevnscrotumvnrelaxesvnandvnb
ecomesvneasyvntovnpalpate.vnThevntesticlevnshouldvnfeelvnsmoothvnandvnround,vnandvnthevn
clientvnshouldvnreportvnanyvnlumpsvntovnhisvnprovider.

Avnnursevnisvncollectingvndatavnfromvnavnclientvnwhovnhasvntuberculosisvnandvnstartedvncom
binationvntherapy
2monthsvnago.vnWhichvnofvnthevnfollowingvndiagnosticvnresultsvnindicatesvnthatvnthevnclientv
nisvnadheringvntovnthe

medicationvnregimen.
-vnAvnnegativevnchestvnX-ray
-vnAvnnegativevnsputumvnculture
-Avnnegativevntuberculinvnskinvntest
-Avnnegativevntitervnforvncytomegalovirusvn-vnanswer--Avnnegativevnsputumvnculture

Tuberculosisvnisvnanvninfectiousvndiseasevnspreadvnthroughvnairbornevndroplets.vnSputumv
nculturesvnarevnobtainedvntovnbothvndiagnosevntuberculosisvnandvntovndeterminevnwhethervn

thevnmedicationvntreatmentvnhasvnbeenvneffective.vnAftervnthevnclientvnbeginsvnantibioticvntr
eatmentvnforvntuberculosis,vnavnsputumvnculturevnisvnobtainedvnmonthly.vnAvnnegativevncult
urevnisvnanvnindicationvnthatvnthevnclientvnisvnnovnlongervninfectiousvnandvnthevnmedicationvnt
herapyvnhasvnbeenvneffective.

Avnnursevnisvncollectingvndatavnfromvnavnclientvnwhovnhasvnbacterialvnmeningitis.vnWhichvnof
vnthevnfollowing

findingsvnshouldvnthevnnursevnexpect?
-vnSeverevnHeadachevn-vnanswer---vnSeverevnHeadache

Thevnnursevnshouldvnexpectvnavnclientvnwhovnhasvnmeningitisvntovnhavevnseverevnandvnpers
istentvnheadachesvnthatvnworsenvnwithvnmovementvnofvnthevnhead.

Avnnursevnisvnreinforcingvnwithvnavnclientvnwhovnhasvnperniciousvnanemia.vnWhichvnofvnthevnf
ollowingvnstatementsvnbyvnthevnclientvnindicatedvnanvnunderstandingvnofvnthevnteaching
-
vnIvnwillvnbevnablevntovnswitchvntovnavnnasalvnformvnofvncyanocobalaminvnwhenvnmyvnlevelsvns

tabilizevn-vnanswer--
Ivnwillvnbevnablevntovnswitchvntovnavnnasalvnformvnofvncyanocobalaminvnwhenvnmyvnlevelsvnst
abilize

AvnnursevnisvnreinforcingvndischargevnteachingvnwithvnavnclientvnwhovnhasvnCOPDvnandvnre
portsvnepisodesvnof
dyspnea.vnWhichvnofvnthevnfollowingvninstructionsvnshouldvnthevnnursevninclude?