RN VATI ADULT MEDICAL SURGICAL ASSESSMENT EXAM
Latest Updated 2024 QUESTIONS WITH DETAILED ANSWERS
Assess the client to determine the need for endotracheal suction every 4 hr.
Evidence-based practice indicates the nurse should assess the client's need for endotrachealsuction
every 2 hr to ensure a clear airway.
Check the ventilator settings every 12 hr.
Evidence-based practice indicates the nurse should check the ventilator settings every 8 hr tomake sure
the settings are at the correct levels.
Keep the head of the client's bed elevated 30°.MY
ANSWER
The nurse should keep the head of the client's bed elevated at least 30° to promote increasedlung
expansion and to help prevent ventilator-associated pneumonia.
Perform oral hygiene with chlorhexidine every 3 hr.
Evidence-based practice indicates the nurse should perform oral hygiene with chlorhexidine every 2 hr
to help prevent ventilator-associated pneumonia from bacteria accumulating in theoral cavity and
colonizing in the lower respiratory system.
High lipase
A high lipase level is associated with pancreatic dysfunction or renal failure and is not anexpected finding
of hyponatremia or dehydration.
Low urine specific gravity
ANSWER
A client who has hyponatremia as a result of diuretic overuse will have a low urine specific gravity. The
increased excretion of water alters the ratio of particulate matter, which affects thespecific gravity.
Low haemoglobin
,A client who is dehydrated as a result of diuretic overuse can have an elevated haemoglobin levelbecause of
the difference in ratio between intravascular fluid and blood cells.
High creatine kinase-MB (CK-MB)
An elevated CK-MB level indicates a myocardial infarction has occurred and is not an expectedfinding of
hyponatremia.
Inspect the client's skin underneath the boot every 12 hr.
The nurse should inspect the client’s skin underneath the boot every 8 hr for irritation, increasedswelling,
and skin breakdown.
Remove the weights from the traction while repositioning the client in bed.
ANSWER
The nurse should not remove the weights from traction without a prescription from the provider. The
purpose of the weight is to immobilize the hip before surgery and to decrease muscles spasms.
Assess the client's circulation every 4 hr.
The nurse should assess the client's circulation hourly for the first 24 hr to monitor for decreasedperfusion
and neurovascular changes.
Request the client to perform dorsiflexion of the affected extremity every 1 hr.
The nurse should request the client to perform dorsiflexion of the affected extremity every 1 hrto assess
if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage.
If this occurs, the nurse should notify the provider immediately.
Stop the blood transfusion immediately.
A client who has type AB-positive blood is considered a universal recipient and can receive any ABO
blood type. A client who has Rh-positive blood can receive a transfusion from a Rh-negative donor.
Prepare to administer antipyretics.
,Febrile reactions are most often caused by leukocyte incompatibilities. Unless a client has a history
of febrile reactions to prior transfusions or shows signs of chills or fever, there is no reason to
administer antipyretics.
Monitor the client for any adverse reactions.
ANSWER
, Although a client is considered a universal recipient because he can receive any ABO blood type,the nurse
should continue to monitor the client for any adverse reactions, which is standard procedure for any
blood transfusion.
Transfuse the blood over 6 hr.
The nurse should transfuse the packed RBCs within 4 hr after removing it from refrigeration toreduce the
risk of bacterial contamination of the blood.
"I will adjust the rate of infusion based on my urinary output."
The nurse should teach the client to monitor urinary output. However, the client should administer PN at
a consistent rate prescribed by the provider. An infusion rate that is too rapidcan cause hyperosmolar
diuresis and hyperglycemia. A rate that is too slow can result in inadequate caloric and nutritional
intake.
"I will need to have a 60-millilitre syringe to administer my PN."
The nurse should teach the client to use an electronic infusion device to prevent the accidental overload
of the intravenous PN solution. A 60-mL syringe is used for intermittent bolus enteral tube feedings.
"I will keep additional solution bags at room temperature."
The nurse should teach the client to refrigerate any PN solution that is not infusing to decrease the risk of
bacterial growth. PN solution is an ideal environment for bacterial growth because ofthe high dextrose
and fat content.
"I will use the aseptic technique when administering my PN."
ANSWER
The nurse should teach the client to use an aseptic technique when connecting the infusion to the
catheter hub to prevent microorganisms from entering the vascular system and causing a catheter-
related bloodstream infection.
Latest Updated 2024 QUESTIONS WITH DETAILED ANSWERS
Assess the client to determine the need for endotracheal suction every 4 hr.
Evidence-based practice indicates the nurse should assess the client's need for endotrachealsuction
every 2 hr to ensure a clear airway.
Check the ventilator settings every 12 hr.
Evidence-based practice indicates the nurse should check the ventilator settings every 8 hr tomake sure
the settings are at the correct levels.
Keep the head of the client's bed elevated 30°.MY
ANSWER
The nurse should keep the head of the client's bed elevated at least 30° to promote increasedlung
expansion and to help prevent ventilator-associated pneumonia.
Perform oral hygiene with chlorhexidine every 3 hr.
Evidence-based practice indicates the nurse should perform oral hygiene with chlorhexidine every 2 hr
to help prevent ventilator-associated pneumonia from bacteria accumulating in theoral cavity and
colonizing in the lower respiratory system.
High lipase
A high lipase level is associated with pancreatic dysfunction or renal failure and is not anexpected finding
of hyponatremia or dehydration.
Low urine specific gravity
ANSWER
A client who has hyponatremia as a result of diuretic overuse will have a low urine specific gravity. The
increased excretion of water alters the ratio of particulate matter, which affects thespecific gravity.
Low haemoglobin
,A client who is dehydrated as a result of diuretic overuse can have an elevated haemoglobin levelbecause of
the difference in ratio between intravascular fluid and blood cells.
High creatine kinase-MB (CK-MB)
An elevated CK-MB level indicates a myocardial infarction has occurred and is not an expectedfinding of
hyponatremia.
Inspect the client's skin underneath the boot every 12 hr.
The nurse should inspect the client’s skin underneath the boot every 8 hr for irritation, increasedswelling,
and skin breakdown.
Remove the weights from the traction while repositioning the client in bed.
ANSWER
The nurse should not remove the weights from traction without a prescription from the provider. The
purpose of the weight is to immobilize the hip before surgery and to decrease muscles spasms.
Assess the client's circulation every 4 hr.
The nurse should assess the client's circulation hourly for the first 24 hr to monitor for decreasedperfusion
and neurovascular changes.
Request the client to perform dorsiflexion of the affected extremity every 1 hr.
The nurse should request the client to perform dorsiflexion of the affected extremity every 1 hrto assess
if the client is experiencing nerve damage. Weakness of dorsiflexion can indicate peroneal nerve damage.
If this occurs, the nurse should notify the provider immediately.
Stop the blood transfusion immediately.
A client who has type AB-positive blood is considered a universal recipient and can receive any ABO
blood type. A client who has Rh-positive blood can receive a transfusion from a Rh-negative donor.
Prepare to administer antipyretics.
,Febrile reactions are most often caused by leukocyte incompatibilities. Unless a client has a history
of febrile reactions to prior transfusions or shows signs of chills or fever, there is no reason to
administer antipyretics.
Monitor the client for any adverse reactions.
ANSWER
, Although a client is considered a universal recipient because he can receive any ABO blood type,the nurse
should continue to monitor the client for any adverse reactions, which is standard procedure for any
blood transfusion.
Transfuse the blood over 6 hr.
The nurse should transfuse the packed RBCs within 4 hr after removing it from refrigeration toreduce the
risk of bacterial contamination of the blood.
"I will adjust the rate of infusion based on my urinary output."
The nurse should teach the client to monitor urinary output. However, the client should administer PN at
a consistent rate prescribed by the provider. An infusion rate that is too rapidcan cause hyperosmolar
diuresis and hyperglycemia. A rate that is too slow can result in inadequate caloric and nutritional
intake.
"I will need to have a 60-millilitre syringe to administer my PN."
The nurse should teach the client to use an electronic infusion device to prevent the accidental overload
of the intravenous PN solution. A 60-mL syringe is used for intermittent bolus enteral tube feedings.
"I will keep additional solution bags at room temperature."
The nurse should teach the client to refrigerate any PN solution that is not infusing to decrease the risk of
bacterial growth. PN solution is an ideal environment for bacterial growth because ofthe high dextrose
and fat content.
"I will use the aseptic technique when administering my PN."
ANSWER
The nurse should teach the client to use an aseptic technique when connecting the infusion to the
catheter hub to prevent microorganisms from entering the vascular system and causing a catheter-
related bloodstream infection.
