MEDSURG VATI ASSESSMENT (New 2026/
2027 Update) Questions & Answers {Grade
A} 100% Correct (Verified Solutions)
A nurse is caring for a client who has type1 diabetes mellitus and has undergone a
below the knee amputation. Which of the following is the highest priority findings
- Skin flap of the residual limb is cool to the touch - correct answer - Skin flap of the
residual limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is that the skin flap of the residual limb is cool to the
touch. The nurse should immediately report this finding to the provider. The skin flap of
the residual limb should be warm to the touch, indicating adequate tissue perfusion.
A nurse is reinforcing teaching before preforming a 12 lead ECG for a client who has
angina pectoris. Which of the following instructions should the nurse include in the
teaching
- Lie still and relax for the procedure - correct answer - Lie still and relax for the
procedure
,The nurse should instruct the client to relax and remain still during the recording of
the ECG because movement and tense muscles can interfere with the results of the
ECG. An ECG is a recording of the client's electrical activity of the heart. The electrical
activity of the heart is detected by electrodes that are placed on the client's trunk and
extremities in specific locations.
A nurse is contributing to the plan of care for a client who is in skeletal traction. Which
of the following interventions should the nurse include
- Keep the clients body centered in the bed - correct answer - Keep the clients body
centered in the bed
The nurse should keep the client's body centered on the bed to maintain alignment of
the body with the direction of the pull of traction. This will ensure continued alignment
of the bone.
A nurse is collecting data from a client who reports amenorrhea and insomnia. Which
of the following data should the nurse report to the provider. Click on exhibit
,-ECG
-Temperature
- BUN
- T4 - correct answer - T4
The client's T4 is above the expected reference range of 4 to 12 mcg/dL, which
indicates hyperthyroidism. The nurse should report this value to the provider so that
treatment for hyperthyroidism can begin.
A nurse is assisting a client who is on bed rest to preform isometric exercises. Which
of the following actions should the nurse take
- Instruct the client to tighten and then relax muscles repeatedly - correct answer -
Instruct the client to tighten and then relax muscles repeatedly
The nurse should instruct the client to perform isometric exercises by holding muscles
tight for 5 seconds and then relaxing them. This form of exercise involves static
contraction of a muscle without any movement of the joint. Immobility can cause
systemic physiologic effects such as increased heart rate, increased bone
, demineralization, decreased muscle strength, joint contractures, and activity
intolerance. Isometric exercises increase muscle mass, tone, and strength while
promoting circulation.
A nurse is reinforcing teaching with a client who has a new prescription for Simvastin.
Which of the following adverse effects should the nurse include in the teaching
- Myalgia - correct answer Myalgia
Simvastatin is a lipid-lowering agent used to treat hypercholesteremia. Adverse
effects of the medication include myalgia, which is muscle pain, and rhabdomyolysis, a
life-threatening destruction of muscle tissue. The nurse should instruct the client to
report the onset of muscle pain, tenderness, and weakness to the provider
immediately.
A nurse is reinforcing teaching about the prevention of STI's with a client who is
sexually active.
Which of the following information should the nurse include in the teaching
2027 Update) Questions & Answers {Grade
A} 100% Correct (Verified Solutions)
A nurse is caring for a client who has type1 diabetes mellitus and has undergone a
below the knee amputation. Which of the following is the highest priority findings
- Skin flap of the residual limb is cool to the touch - correct answer - Skin flap of the
residual limb is cool to the touch
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding is that the skin flap of the residual limb is cool to the
touch. The nurse should immediately report this finding to the provider. The skin flap of
the residual limb should be warm to the touch, indicating adequate tissue perfusion.
A nurse is reinforcing teaching before preforming a 12 lead ECG for a client who has
angina pectoris. Which of the following instructions should the nurse include in the
teaching
- Lie still and relax for the procedure - correct answer - Lie still and relax for the
procedure
,The nurse should instruct the client to relax and remain still during the recording of
the ECG because movement and tense muscles can interfere with the results of the
ECG. An ECG is a recording of the client's electrical activity of the heart. The electrical
activity of the heart is detected by electrodes that are placed on the client's trunk and
extremities in specific locations.
A nurse is contributing to the plan of care for a client who is in skeletal traction. Which
of the following interventions should the nurse include
- Keep the clients body centered in the bed - correct answer - Keep the clients body
centered in the bed
The nurse should keep the client's body centered on the bed to maintain alignment of
the body with the direction of the pull of traction. This will ensure continued alignment
of the bone.
A nurse is collecting data from a client who reports amenorrhea and insomnia. Which
of the following data should the nurse report to the provider. Click on exhibit
,-ECG
-Temperature
- BUN
- T4 - correct answer - T4
The client's T4 is above the expected reference range of 4 to 12 mcg/dL, which
indicates hyperthyroidism. The nurse should report this value to the provider so that
treatment for hyperthyroidism can begin.
A nurse is assisting a client who is on bed rest to preform isometric exercises. Which
of the following actions should the nurse take
- Instruct the client to tighten and then relax muscles repeatedly - correct answer -
Instruct the client to tighten and then relax muscles repeatedly
The nurse should instruct the client to perform isometric exercises by holding muscles
tight for 5 seconds and then relaxing them. This form of exercise involves static
contraction of a muscle without any movement of the joint. Immobility can cause
systemic physiologic effects such as increased heart rate, increased bone
, demineralization, decreased muscle strength, joint contractures, and activity
intolerance. Isometric exercises increase muscle mass, tone, and strength while
promoting circulation.
A nurse is reinforcing teaching with a client who has a new prescription for Simvastin.
Which of the following adverse effects should the nurse include in the teaching
- Myalgia - correct answer Myalgia
Simvastatin is a lipid-lowering agent used to treat hypercholesteremia. Adverse
effects of the medication include myalgia, which is muscle pain, and rhabdomyolysis, a
life-threatening destruction of muscle tissue. The nurse should instruct the client to
report the onset of muscle pain, tenderness, and weakness to the provider
immediately.
A nurse is reinforcing teaching about the prevention of STI's with a client who is
sexually active.
Which of the following information should the nurse include in the teaching
