RN VATI Adult Medical Surgical
Assessment. Questions and
Answers/Updated Version
Question 1
A nurse is caring for a client admitted with heart failure exacerbation. Which assessment finding
indicates fluid volume excess?
A. Flat neck veins when sitting upright
B. Crackles heard in both lung bases
C. Dry mucous membranes
D. Increased hematocrit
Rationale: Heart failure causes decreased cardiac output, leading to fluid backup into the
pulmonary circulation and pulmonary edema. Crackles indicate fluid accumulation in the alveoli.
Flat neck veins suggest hypovolemia, dry mucous membranes indicate dehydration, and
elevated hematocrit is associated with fluid deficit. Nurses should always assess lung sounds,
oxygen saturation, daily weights, and edema in clients with heart failure.
Question 2
A nurse is caring for a client who has heart failure and is receiving furosemide. Which laboratory
value should the nurse monitor most closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Rationale: Furosemide is a loop diuretic that causes potassium wasting, leading to
hypokalemia. Hypokalemia can precipitate cardiac dysrhythmias, especially in clients taking
digoxin. Serum potassium should be monitored closely and replaced as needed.
Question 3
A nurse is preparing to administer digoxin to a client who has heart failure. Which assessment
finding indicates the need to withhold the medication?
, A. Heart rate 58 bpm
B. Blood pressure 110/70 mmHg
C. Respiratory rate 18 breaths/min
D. Serum potassium 4.0 mEq/L
Rationale: Digoxin should be withheld if the heart rate is < 60 bpm in adults. The healthcare
provider should be notified. Blood pressure, respiratory rate, and potassium level are within
normal limits.
Question 4 (SATA)
A nurse is assessing a client with left-sided heart failure. Which findings should the nurse
expect? Select all that apply.
A. Crackles in lung bases
B. Jugular venous distention
C. Orthopnea
D. Peripheral edema
E. Pink frothy sputum
Rationale: Left-sided heart failure causes pulmonary congestion, leading to crackles,
orthopnea, and pink frothy sputum. Right-sided heart failure causes systemic congestion,
leading to jugular venous distention and peripheral edema.
Question 5
A nurse is providing discharge teaching to a client with heart failure. Which statement by the
client indicates a need for further teaching?
A. "I will weigh myself daily and report a gain of 3 pounds in one week."
B. "I will avoid adding salt to my food at the table."
C. "I will take my furosemide at bedtime."
D. "I will elevate my legs when sitting."
Rationale: Diuretics should be taken in the morning to prevent nocturia and disruption of
sleep. Daily weight monitoring, sodium restriction, and leg elevation are appropriate self-care
measures.
1.2 Acute Coronary Syndrome & Myocardial Infarction
,Question 6
A 58-year-old client presents with severe chest pain radiating to the left arm, shortness of
breath, and diaphoresis. Which nursing intervention should be the priority?
A. Obtain a 12-lead electrocardiogram (ECG)
B. Establish IV access and apply oxygen
C. Administer aspirin 325 mg orally
D. Notify the healthcare provider immediately
Rationale: Establishing IV access and applying oxygen addresses the immediate
physiological needs of a client experiencing acute coronary syndrome. Oxygen therapy improves
tissue oxygenation, and IV access ensures immediate medication administration capability. An
ECG and aspirin are important but should follow after basic stabilization measures.
Question 7
A nurse is assessing a client who has unstable angina. Which finding should the nurse expect?
A. Chest pain that is relieved by rest and nitroglycerin
B. Chest pain that occurs at rest and is not relieved by nitroglycerin
C. Chest pain that is worse with deep inspiration
D. Chest pain that radiates to the right shoulder
Rationale: Unstable angina is characterized by chest pain that occurs at rest or with minimal
exertion and is not readily relieved by nitroglycerin. This indicates an acute coronary syndrome
requiring immediate medical evaluation.
Question 8
A nurse is caring for a client following a myocardial infarction. Which finding is most concerning?
A. Chest pain rated 6 on a scale of 0–10
B. Jugular venous distention
C. Crackles heard in the lung bases
D. New-onset heart block
Rationale: New-onset heart block following MI indicates conduction system ischemia and
can progress to complete heart block or asystole. This requires immediate intervention. While
chest pain, JVD, and crackles are important findings, they do not carry the same immediate risk
of hemodynamic collapse.
, Question 9
A client with acute coronary syndrome is prescribed morphine sulfate. Which finding indicates
the medication is effective?
A. Blood pressure increases
B. Heart rate increases
C. Chest pain decreases
D. Respiratory rate increases
Rationale: Morphine is administered for pain relief in acute coronary syndrome. It also
reduces myocardial oxygen demand through vasodilation and decreased heart rate. Effective
pain relief is the primary indicator of therapeutic effect.
Question 10 (SATA)
A nurse is teaching a client about nitroglycerin. Which instructions should the nurse
include? Select all that apply.
A. "Place one tablet under your tongue and let it dissolve."
B. "You may take up to three doses, five minutes apart."
C. "Swallow the tablet with a full glass of water."
D. "Call 911 if chest pain is not relieved after one dose."
E. "Store the tablets in a dark, tightly closed container."
Rationale: Sublingual nitroglycerin should be dissolved under the tongue, not swallowed.
Up to three doses may be taken five minutes apart. Clients should call 911 if pain persists after
the first dose (in the prehospital setting) or after three doses (per current guidelines).
Nitroglycerin is light-sensitive and should be stored properly.
1.3 Dysrhythmias & Anticoagulation
Question 11
A nurse is reviewing the medical record of a client taking warfarin for chronic atrial fibrillation.
Which INR value should the nurse identify as therapeutic?
A. 1.2
B. 2.5
Assessment. Questions and
Answers/Updated Version
Question 1
A nurse is caring for a client admitted with heart failure exacerbation. Which assessment finding
indicates fluid volume excess?
A. Flat neck veins when sitting upright
B. Crackles heard in both lung bases
C. Dry mucous membranes
D. Increased hematocrit
Rationale: Heart failure causes decreased cardiac output, leading to fluid backup into the
pulmonary circulation and pulmonary edema. Crackles indicate fluid accumulation in the alveoli.
Flat neck veins suggest hypovolemia, dry mucous membranes indicate dehydration, and
elevated hematocrit is associated with fluid deficit. Nurses should always assess lung sounds,
oxygen saturation, daily weights, and edema in clients with heart failure.
Question 2
A nurse is caring for a client who has heart failure and is receiving furosemide. Which laboratory
value should the nurse monitor most closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Rationale: Furosemide is a loop diuretic that causes potassium wasting, leading to
hypokalemia. Hypokalemia can precipitate cardiac dysrhythmias, especially in clients taking
digoxin. Serum potassium should be monitored closely and replaced as needed.
Question 3
A nurse is preparing to administer digoxin to a client who has heart failure. Which assessment
finding indicates the need to withhold the medication?
, A. Heart rate 58 bpm
B. Blood pressure 110/70 mmHg
C. Respiratory rate 18 breaths/min
D. Serum potassium 4.0 mEq/L
Rationale: Digoxin should be withheld if the heart rate is < 60 bpm in adults. The healthcare
provider should be notified. Blood pressure, respiratory rate, and potassium level are within
normal limits.
Question 4 (SATA)
A nurse is assessing a client with left-sided heart failure. Which findings should the nurse
expect? Select all that apply.
A. Crackles in lung bases
B. Jugular venous distention
C. Orthopnea
D. Peripheral edema
E. Pink frothy sputum
Rationale: Left-sided heart failure causes pulmonary congestion, leading to crackles,
orthopnea, and pink frothy sputum. Right-sided heart failure causes systemic congestion,
leading to jugular venous distention and peripheral edema.
Question 5
A nurse is providing discharge teaching to a client with heart failure. Which statement by the
client indicates a need for further teaching?
A. "I will weigh myself daily and report a gain of 3 pounds in one week."
B. "I will avoid adding salt to my food at the table."
C. "I will take my furosemide at bedtime."
D. "I will elevate my legs when sitting."
Rationale: Diuretics should be taken in the morning to prevent nocturia and disruption of
sleep. Daily weight monitoring, sodium restriction, and leg elevation are appropriate self-care
measures.
1.2 Acute Coronary Syndrome & Myocardial Infarction
,Question 6
A 58-year-old client presents with severe chest pain radiating to the left arm, shortness of
breath, and diaphoresis. Which nursing intervention should be the priority?
A. Obtain a 12-lead electrocardiogram (ECG)
B. Establish IV access and apply oxygen
C. Administer aspirin 325 mg orally
D. Notify the healthcare provider immediately
Rationale: Establishing IV access and applying oxygen addresses the immediate
physiological needs of a client experiencing acute coronary syndrome. Oxygen therapy improves
tissue oxygenation, and IV access ensures immediate medication administration capability. An
ECG and aspirin are important but should follow after basic stabilization measures.
Question 7
A nurse is assessing a client who has unstable angina. Which finding should the nurse expect?
A. Chest pain that is relieved by rest and nitroglycerin
B. Chest pain that occurs at rest and is not relieved by nitroglycerin
C. Chest pain that is worse with deep inspiration
D. Chest pain that radiates to the right shoulder
Rationale: Unstable angina is characterized by chest pain that occurs at rest or with minimal
exertion and is not readily relieved by nitroglycerin. This indicates an acute coronary syndrome
requiring immediate medical evaluation.
Question 8
A nurse is caring for a client following a myocardial infarction. Which finding is most concerning?
A. Chest pain rated 6 on a scale of 0–10
B. Jugular venous distention
C. Crackles heard in the lung bases
D. New-onset heart block
Rationale: New-onset heart block following MI indicates conduction system ischemia and
can progress to complete heart block or asystole. This requires immediate intervention. While
chest pain, JVD, and crackles are important findings, they do not carry the same immediate risk
of hemodynamic collapse.
, Question 9
A client with acute coronary syndrome is prescribed morphine sulfate. Which finding indicates
the medication is effective?
A. Blood pressure increases
B. Heart rate increases
C. Chest pain decreases
D. Respiratory rate increases
Rationale: Morphine is administered for pain relief in acute coronary syndrome. It also
reduces myocardial oxygen demand through vasodilation and decreased heart rate. Effective
pain relief is the primary indicator of therapeutic effect.
Question 10 (SATA)
A nurse is teaching a client about nitroglycerin. Which instructions should the nurse
include? Select all that apply.
A. "Place one tablet under your tongue and let it dissolve."
B. "You may take up to three doses, five minutes apart."
C. "Swallow the tablet with a full glass of water."
D. "Call 911 if chest pain is not relieved after one dose."
E. "Store the tablets in a dark, tightly closed container."
Rationale: Sublingual nitroglycerin should be dissolved under the tongue, not swallowed.
Up to three doses may be taken five minutes apart. Clients should call 911 if pain persists after
the first dose (in the prehospital setting) or after three doses (per current guidelines).
Nitroglycerin is light-sensitive and should be stored properly.
1.3 Dysrhythmias & Anticoagulation
Question 11
A nurse is reviewing the medical record of a client taking warfarin for chronic atrial fibrillation.
Which INR value should the nurse identify as therapeutic?
A. 1.2
B. 2.5
