MEDSURG VATI ASSESSMENT (New 2026/
2027 Update) Questions & Answers {Grade
A} 100% Correct (Verified Solutions)
A nurse is collecting data from a client who reports dizziness, vertigo, and is
preforming the
Romberg test. Which of the following instructions should the nurse give the clients
about this test.
- stand with your feet a part
-hold your arm out in front of you
- Open your eyes
- walking straight line - correct answer Open your eyes
The nurse should instruct the client to stand with their feet together and eyes open.
Then the client should close their eyes to determine if they lose balance. The test is
negative if the client can remain upright and keep balance with minimal swaying and
without moving their feet to another position. A positive test can indicate a dysfunction
of the cerebellum or inner ear.
,A nurse examining a client's rhythm strips notices no visible P waves but many small,
erratic
spikes throughout the strip as well as variable ventricular rate. The nurse should
identify and
report this pattern as which of the following dysrhythmias?
- Atrial Fibrillation - correct answer - Atrial Fibrillation
The nurse should identify that during atrial fibrillation, the atrioventricular node cannot
respond to so many atrial impulses. Therefore, it sends impulses to the ventricles in an
erratic way, which accounts for these characteristics on the client's rhythm strip.
A nurse is preparing to obtain informed consent for a client who is scheduled to have a
total
laryngectomy with a tracheostomy. The nurse should identify that which of the
following client
statements indicates an understanding of the procedure
- There will be a hole in my neck after this procedure - correct answer - There will be
a hole in my neck after this procedure
,The nurse should identify that this statement indicates the client understands the
procedure and can proceed to obtain informed consent. A client who has a total
laryngectomy will have a permanent tracheostomy stoma placed in the neck for
breathing because the upper airway will be separated from the throat and esophagus.
A nurse is administering a tap water enema to a client who has constipation. The client
reports
abdominal cramping during instillation of the enema. Which of the following actions
should the
nurse take
- Slow the rate of fluid flow - correct answer - Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the intestinal spasm
to pass if cramping occurs during administration of the enema. Lowering the height of
the enema bag will decrease the rate the fluid enters the bowel. Tap water enemas
consist of 500 mL to 1 L of fluid that is instilled into the bowel to soften feces. The
volume of fluid stimulates peristalsis.
, A nurse is caring for a client who is receiving continuous bladder irrigation following a
transurethral resection of the prostate. The client has reduced urinary output, red
urine, and reports bladder pain. Which of the following action should the nurse take
first? - correct answer - Increase the flow rate of the irrigation
When providing client care, the nurse should use the least restrictive intervention first;
therefore, the nurse should first increase the flow rate of continuous bladder irrigation
to keep the urinary output light pink or yellow.
A nurse is contributing to the plan for a client who has dysphagia following a stroke.
Which of the following actions should the nurse include in the plan of care to prevent
aspiration? - correct answer - Keep the client upright for 30 mins after a meal.
The nurse should keep the client upright for 30 to 60 min after a meal to reduce the
risk for aspiration.
2027 Update) Questions & Answers {Grade
A} 100% Correct (Verified Solutions)
A nurse is collecting data from a client who reports dizziness, vertigo, and is
preforming the
Romberg test. Which of the following instructions should the nurse give the clients
about this test.
- stand with your feet a part
-hold your arm out in front of you
- Open your eyes
- walking straight line - correct answer Open your eyes
The nurse should instruct the client to stand with their feet together and eyes open.
Then the client should close their eyes to determine if they lose balance. The test is
negative if the client can remain upright and keep balance with minimal swaying and
without moving their feet to another position. A positive test can indicate a dysfunction
of the cerebellum or inner ear.
,A nurse examining a client's rhythm strips notices no visible P waves but many small,
erratic
spikes throughout the strip as well as variable ventricular rate. The nurse should
identify and
report this pattern as which of the following dysrhythmias?
- Atrial Fibrillation - correct answer - Atrial Fibrillation
The nurse should identify that during atrial fibrillation, the atrioventricular node cannot
respond to so many atrial impulses. Therefore, it sends impulses to the ventricles in an
erratic way, which accounts for these characteristics on the client's rhythm strip.
A nurse is preparing to obtain informed consent for a client who is scheduled to have a
total
laryngectomy with a tracheostomy. The nurse should identify that which of the
following client
statements indicates an understanding of the procedure
- There will be a hole in my neck after this procedure - correct answer - There will be
a hole in my neck after this procedure
,The nurse should identify that this statement indicates the client understands the
procedure and can proceed to obtain informed consent. A client who has a total
laryngectomy will have a permanent tracheostomy stoma placed in the neck for
breathing because the upper airway will be separated from the throat and esophagus.
A nurse is administering a tap water enema to a client who has constipation. The client
reports
abdominal cramping during instillation of the enema. Which of the following actions
should the
nurse take
- Slow the rate of fluid flow - correct answer - Slow the rate of fluid flow
The nurse should slow down the flow of the enema fluid to allow the intestinal spasm
to pass if cramping occurs during administration of the enema. Lowering the height of
the enema bag will decrease the rate the fluid enters the bowel. Tap water enemas
consist of 500 mL to 1 L of fluid that is instilled into the bowel to soften feces. The
volume of fluid stimulates peristalsis.
, A nurse is caring for a client who is receiving continuous bladder irrigation following a
transurethral resection of the prostate. The client has reduced urinary output, red
urine, and reports bladder pain. Which of the following action should the nurse take
first? - correct answer - Increase the flow rate of the irrigation
When providing client care, the nurse should use the least restrictive intervention first;
therefore, the nurse should first increase the flow rate of continuous bladder irrigation
to keep the urinary output light pink or yellow.
A nurse is contributing to the plan for a client who has dysphagia following a stroke.
Which of the following actions should the nurse include in the plan of care to prevent
aspiration? - correct answer - Keep the client upright for 30 mins after a meal.
The nurse should keep the client upright for 30 to 60 min after a meal to reduce the
risk for aspiration.
