VATI RN MED-SURG ASSESSMENT TEST
QUESTIONS WITH ANSWERS (100%
CORRECT ANSWERS) 2026/2027
1. A nurse is caring for a client admitted with acute heart failure. Which
assessment finding requires immediate intervention?
A. Bilateral 2+ pitting edema in the ankles
B. Blood pressure of 150/90 mm Hg
C. Crackles throughout both lung fields and oxygen saturation of 84%
D. Weight gain of 2 lb (0.9 kg) over 24 hours
Correct Answer: C
Rationale: This client is experiencing severe pulmonary edema, resulting in impaired gas
exchange and hypoxemia. An oxygen saturation of 84% indicates inadequate
oxygenation requiring immediate intervention. Peripheral edema indicates fluid overload
but is not immediately life-threatening. Mild hypertension is common in heart failure
and is less urgent. Rapid weight gain signals worsening fluid retention but is not as
immediately dangerous as hypoxia. Nursing Priority: Use the ABCs (Airway, Breathing,
Circulation). Oxygenation always takes priority.
2. A client with left-sided heart failure is being assessed. Which finding should the
nurse identify as a manifestation of left-sided heart failure?
A. Dependent edema in the lower extremities
B. Pink-tinged frothy sputum
C. Jugular vein distention
D. Hepatomegaly
Correct Answer: B
Rationale: Pink-tinged frothy sputum indicates pulmonary edema, a key manifestation
of left-sided heart failure due to backup of blood into the pulmonary circulation.
Dependent edema, JVD, and hepatomegaly are signs of right-sided heart failure.
,3. A nurse is preparing to administer a transfusion of packed RBCs to a client who
has heart failure. For which manifestations should the nurse monitor to prevent
fluid volume overload? (Select all that apply.)
A. Dyspnea
B. Gastrointestinal bloating
C. Jugular vein distention
D. Confusion
E. Hypotension
Correct Answer: A, C, D
Rationale: Signs of fluid volume overload include dyspnea (due to pulmonary
congestion), jugular vein distention (due to increased central venous pressure), and
confusion (due to cerebral edema). Gastrointestinal bloating and hypotension are not
primary signs of fluid volume overload.
4. A client receiving packed red blood cells suddenly develops chills, fever, and
flank pain. What should the nurse do first?
A. Notify the provider
B. Slow the infusion
C. Stop the transfusion
D. Administer acetaminophen
Correct Answer: C
Rationale: These findings suggest an acute hemolytic transfusion reaction. Immediate
actions include stopping the transfusion, maintaining IV access with normal saline using
new tubing, notifying the provider and blood bank, monitoring vital signs, and
obtaining blood and urine specimens as ordered. Stopping the transfusion prevents
further exposure to incompatible blood.
5. A client with atrial fibrillation is prescribed warfarin. The nurse educates the
client that they must avoid eating large amounts of which foods?
A. Bananas and oranges
B. Green leafy vegetables (spinach, kale)
C. Grapefruit juice
D. Dairy products
,Correct Answer: B
Rationale: Green leafy vegetables are high in Vitamin K, which antagonizes the effect of
warfarin. Patients should maintain consistent Vitamin K intake rather than avoid it
completely. Grapefruit juice is a concern with statins and calcium channel blockers, not
warfarin.
6. A nurse is monitoring a client who is receiving opioid analgesia. Which findings
should the nurse identify as adverse effects of opioid analgesics? (Select all that
apply.)
A. Urinary incontinence
B. Diarrhea
C. Bradypnea
D. Orthostatic hypotension
E. Nausea
Correct Answer: C, D, E
Rationale: Adverse effects of opioids include bradypnea (respiratory depression),
orthostatic hypotension, nausea, constipation (not diarrhea), and urinary retention (not
incontinence).
7. A client with deep vein thrombosis is started on IV heparin. Which laboratory
value should the nurse monitor to evaluate the therapeutic efficacy of heparin?
A. PT/INR
B. aPTT
C. Platelet count
D. D-dimer
Correct Answer: B
Rationale: Heparin is monitored using the aPTT. The goal is typically 1.5-2.5 times the
control value. PT/INR is used to monitor warfarin. Platelet count is monitored to detect
HIT. D-dimer is a diagnostic test for DVT/PE.
8. A client on warfarin has an INR of 4.5 without bleeding. Which action is most
appropriate?
A. Administer vitamin K 10 mg subcutaneously
B. Withhold warfarin and recheck INR in 24-48 hours
, C. Give fresh frozen plasma immediately
D. Increase warfarin dose
Correct Answer: B
Rationale: For an asymptomatic patient with INR 4.5-10, guidelines recommend
withholding warfarin (no vitamin K unless high bleeding risk). Recheck INR in 1-2 days.
Vitamin K is for INR >10 or active bleeding.
9. A patient on clopidogrel is scheduled for elective surgery. When should
clopidogrel be stopped?
A. 2 days before surgery
B. 5 days before surgery
C. 10 days before surgery
D. 14 days before surgery
Correct Answer: B
Rationale: Clopidogrel irreversibly inhibits P2Y12; platelet function recovers in 5-7 days
(new platelets). Guidelines recommend stopping 5 days pre-op for most non-cardiac
surgeries.
10. A nurse is assessing a client who is 12 hours postoperative following a total hip
arthroplasty. Which finding requires immediate intervention?
A. Pain rated 6 on a 0-10 scale
B. Temperature of 100.2°F (37.9°C)
C. Sudden shortness of breath and chest pain
D. Drainage of 50 mL of serosanguineous fluid from the surgical drain
Correct Answer: C
Rationale: Sudden dyspnea and chest pain in a postoperative orthopedic client strongly
suggest a pulmonary embolism (PE), a life-threatening complication requiring
immediate intervention. Moderate postoperative pain is expected; slight temperature
elevation during the first 24 hours may occur due to inflammation; moderate
serosanguineous drainage is expected after surgery.
11. The nurse receives all of the following stat orders for a patient with a
pulmonary embolism. Which one should the nurse question?
1. Oxygen per nasal cannula at 4 L per minute
QUESTIONS WITH ANSWERS (100%
CORRECT ANSWERS) 2026/2027
1. A nurse is caring for a client admitted with acute heart failure. Which
assessment finding requires immediate intervention?
A. Bilateral 2+ pitting edema in the ankles
B. Blood pressure of 150/90 mm Hg
C. Crackles throughout both lung fields and oxygen saturation of 84%
D. Weight gain of 2 lb (0.9 kg) over 24 hours
Correct Answer: C
Rationale: This client is experiencing severe pulmonary edema, resulting in impaired gas
exchange and hypoxemia. An oxygen saturation of 84% indicates inadequate
oxygenation requiring immediate intervention. Peripheral edema indicates fluid overload
but is not immediately life-threatening. Mild hypertension is common in heart failure
and is less urgent. Rapid weight gain signals worsening fluid retention but is not as
immediately dangerous as hypoxia. Nursing Priority: Use the ABCs (Airway, Breathing,
Circulation). Oxygenation always takes priority.
2. A client with left-sided heart failure is being assessed. Which finding should the
nurse identify as a manifestation of left-sided heart failure?
A. Dependent edema in the lower extremities
B. Pink-tinged frothy sputum
C. Jugular vein distention
D. Hepatomegaly
Correct Answer: B
Rationale: Pink-tinged frothy sputum indicates pulmonary edema, a key manifestation
of left-sided heart failure due to backup of blood into the pulmonary circulation.
Dependent edema, JVD, and hepatomegaly are signs of right-sided heart failure.
,3. A nurse is preparing to administer a transfusion of packed RBCs to a client who
has heart failure. For which manifestations should the nurse monitor to prevent
fluid volume overload? (Select all that apply.)
A. Dyspnea
B. Gastrointestinal bloating
C. Jugular vein distention
D. Confusion
E. Hypotension
Correct Answer: A, C, D
Rationale: Signs of fluid volume overload include dyspnea (due to pulmonary
congestion), jugular vein distention (due to increased central venous pressure), and
confusion (due to cerebral edema). Gastrointestinal bloating and hypotension are not
primary signs of fluid volume overload.
4. A client receiving packed red blood cells suddenly develops chills, fever, and
flank pain. What should the nurse do first?
A. Notify the provider
B. Slow the infusion
C. Stop the transfusion
D. Administer acetaminophen
Correct Answer: C
Rationale: These findings suggest an acute hemolytic transfusion reaction. Immediate
actions include stopping the transfusion, maintaining IV access with normal saline using
new tubing, notifying the provider and blood bank, monitoring vital signs, and
obtaining blood and urine specimens as ordered. Stopping the transfusion prevents
further exposure to incompatible blood.
5. A client with atrial fibrillation is prescribed warfarin. The nurse educates the
client that they must avoid eating large amounts of which foods?
A. Bananas and oranges
B. Green leafy vegetables (spinach, kale)
C. Grapefruit juice
D. Dairy products
,Correct Answer: B
Rationale: Green leafy vegetables are high in Vitamin K, which antagonizes the effect of
warfarin. Patients should maintain consistent Vitamin K intake rather than avoid it
completely. Grapefruit juice is a concern with statins and calcium channel blockers, not
warfarin.
6. A nurse is monitoring a client who is receiving opioid analgesia. Which findings
should the nurse identify as adverse effects of opioid analgesics? (Select all that
apply.)
A. Urinary incontinence
B. Diarrhea
C. Bradypnea
D. Orthostatic hypotension
E. Nausea
Correct Answer: C, D, E
Rationale: Adverse effects of opioids include bradypnea (respiratory depression),
orthostatic hypotension, nausea, constipation (not diarrhea), and urinary retention (not
incontinence).
7. A client with deep vein thrombosis is started on IV heparin. Which laboratory
value should the nurse monitor to evaluate the therapeutic efficacy of heparin?
A. PT/INR
B. aPTT
C. Platelet count
D. D-dimer
Correct Answer: B
Rationale: Heparin is monitored using the aPTT. The goal is typically 1.5-2.5 times the
control value. PT/INR is used to monitor warfarin. Platelet count is monitored to detect
HIT. D-dimer is a diagnostic test for DVT/PE.
8. A client on warfarin has an INR of 4.5 without bleeding. Which action is most
appropriate?
A. Administer vitamin K 10 mg subcutaneously
B. Withhold warfarin and recheck INR in 24-48 hours
, C. Give fresh frozen plasma immediately
D. Increase warfarin dose
Correct Answer: B
Rationale: For an asymptomatic patient with INR 4.5-10, guidelines recommend
withholding warfarin (no vitamin K unless high bleeding risk). Recheck INR in 1-2 days.
Vitamin K is for INR >10 or active bleeding.
9. A patient on clopidogrel is scheduled for elective surgery. When should
clopidogrel be stopped?
A. 2 days before surgery
B. 5 days before surgery
C. 10 days before surgery
D. 14 days before surgery
Correct Answer: B
Rationale: Clopidogrel irreversibly inhibits P2Y12; platelet function recovers in 5-7 days
(new platelets). Guidelines recommend stopping 5 days pre-op for most non-cardiac
surgeries.
10. A nurse is assessing a client who is 12 hours postoperative following a total hip
arthroplasty. Which finding requires immediate intervention?
A. Pain rated 6 on a 0-10 scale
B. Temperature of 100.2°F (37.9°C)
C. Sudden shortness of breath and chest pain
D. Drainage of 50 mL of serosanguineous fluid from the surgical drain
Correct Answer: C
Rationale: Sudden dyspnea and chest pain in a postoperative orthopedic client strongly
suggest a pulmonary embolism (PE), a life-threatening complication requiring
immediate intervention. Moderate postoperative pain is expected; slight temperature
elevation during the first 24 hours may occur due to inflammation; moderate
serosanguineous drainage is expected after surgery.
11. The nurse receives all of the following stat orders for a patient with a
pulmonary embolism. Which one should the nurse question?
1. Oxygen per nasal cannula at 4 L per minute
