VATI Med Surge Assessment.
A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone ointment.
The nurse should assess the client to monitor for which of the following adverse effects? ANS: Thinning
of the skin.
Only apply the ointment to dry patches of the skin to avoid atrophy.
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the
nurse identify as a manifestation of left-sided heart failure? ANS: Frothy sputum
Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening.
Therefore, the nurse should notify the provider immediately.
A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and
fingers.
The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm Hg. Which of the
following acid-base imbalances should the nurse identify that the client is experiencing? ANS:
Respiratory alkalosis
- The pH is alkaline (increased)
- PCO2 is decreased representing alveolar hyperventilation & resultant respiratory alkalosis
A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the
nurse expect? ANS: Osteoporosis
Bone become thinner as a result of mineral loss & nitrogen depletion.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of
the following lesion characteristics on the client's skin? ANS: A pearly, waxy nodule.
,- Basal cell carcinoma has a nodular lesion with well defined borders & pearly or waxy appearance
resulting from overexposure to the sun. especially on the face, head, and neck.
-A client who has melanoma has a lesion with irregular borders and variegated colors of red, white, and
blue, most often on the upper back or lower legs.
-A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion with a ulcerated
center, resulting from sun exposure, chronic irritation, burns, or irradiation to the skin.
A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a
sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect? ANS:
LOW URINE SPECFIC GRAVITY.
-A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity. The
increased excretion of water alters the ratio of particulate matter, which affects the specific gravity.
A home health nurse is assisting a client with planning care for a family member who has Alzheimer's
disease. Which of the following instructions should the nurse include? ANS: Remove clutter from rooms
and hallways
- This allows the client is able to walk without the risk of falling or tripping over objects. Later in the
disease, the client can experience seizures, so cluttered areas could be a risk to the client
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of
the following findings should the nurse identify as a manifestation of this syndrome? ANS: REFRACTORY
HYPOXEMIA
- A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not improve with
oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a manifestation of ARDS.
An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the
following findings should indicate to the nurse that the client is experiencing status asthmaticus? ANS:
USE OF ASSCESSORY MUSCLES.
, - A client who has status asthmaticus uses accessory muscles to help facilitate breathing, which is a
manifestation of a severe airflow obstruction. The situation is life-threatening and the nurse should
intervene immediately with strong systemic bronchodilators, epinephrine, corticosteroids, and oxygen.
A nurse is teaching a client who has a new prescription for PHENYTOIN to treat a seizure disorder. Which
of the following adverse effects should the nurse instruct the client to report IMMEDIATELY to the
provider? ANS: SKIN RASH.
- the nurse should determine that the priority finding is a rash, which can have a measles-like
appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The client should
report this finding to the provider immediately.
A nurse is monitoring a client following a LUMBAR LAMINECTOMY. The client has a drain and indwelling
urinary catheter. The nurse should identify which of the following findings as an indication of a
COMPLICATION of the surgery? ANS: CLEAR DRAINAGE OF DRESSINGS
- This is an indication of a cerebral spinal leak
A nurse is assessing a client who has RIGHT-SIDED HEART FAILURE. Which of the following findings
should the nurse identify as a manifestation of RIGHT- SIDED HEART FAILURE? ANS: INCREASED
ABDOMINAL GIRTH
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have
chronic illnesses. The nurse should identify that which of the following statements by the client indicates
ACCEPTANCE of the role change? ANS: " I changed the floor plan of our homes to accommodate my
father's wheelchair. "
A nurse is caring for a client who is receiving VANCOMYCIN intermittent IV bolus therapy for
METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS. Which of the following findings is an indication to
the nurse that the client is experiencing an ADVERSE EFFECT of the medication? ANS: THE CLIENT IS
BECOMING FLUSHED.
A nurse is caring for a client who has atopic dermatitis and a prescription for triamcinolone ointment.
The nurse should assess the client to monitor for which of the following adverse effects? ANS: Thinning
of the skin.
Only apply the ointment to dry patches of the skin to avoid atrophy.
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the
nurse identify as a manifestation of left-sided heart failure? ANS: Frothy sputum
Pink-tinged frothy sputum can be an early indication of pulmonary edema and can be life-threatening.
Therefore, the nurse should notify the provider immediately.
A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and
fingers.
The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm Hg. Which of the
following acid-base imbalances should the nurse identify that the client is experiencing? ANS:
Respiratory alkalosis
- The pH is alkaline (increased)
- PCO2 is decreased representing alveolar hyperventilation & resultant respiratory alkalosis
A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the
nurse expect? ANS: Osteoporosis
Bone become thinner as a result of mineral loss & nitrogen depletion.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of
the following lesion characteristics on the client's skin? ANS: A pearly, waxy nodule.
,- Basal cell carcinoma has a nodular lesion with well defined borders & pearly or waxy appearance
resulting from overexposure to the sun. especially on the face, head, and neck.
-A client who has melanoma has a lesion with irregular borders and variegated colors of red, white, and
blue, most often on the upper back or lower legs.
-A client who has squamous cell carcinoma has a firm, nodular, and crusty lesion with a ulcerated
center, resulting from sun exposure, chronic irritation, burns, or irradiation to the skin.
A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a
sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect? ANS:
LOW URINE SPECFIC GRAVITY.
-A client who has hyponatremia as a result of diuretic overuse has a low urine specific gravity. The
increased excretion of water alters the ratio of particulate matter, which affects the specific gravity.
A home health nurse is assisting a client with planning care for a family member who has Alzheimer's
disease. Which of the following instructions should the nurse include? ANS: Remove clutter from rooms
and hallways
- This allows the client is able to walk without the risk of falling or tripping over objects. Later in the
disease, the client can experience seizures, so cluttered areas could be a risk to the client
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of
the following findings should the nurse identify as a manifestation of this syndrome? ANS: REFRACTORY
HYPOXEMIA
- A client who has ARDS has refractory hypoxemia, which is hypoxemia that does not improve with
oxygen therapy. Extensive pulmonary edema evident on a chest x-ray is a manifestation of ARDS.
An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the
following findings should indicate to the nurse that the client is experiencing status asthmaticus? ANS:
USE OF ASSCESSORY MUSCLES.
, - A client who has status asthmaticus uses accessory muscles to help facilitate breathing, which is a
manifestation of a severe airflow obstruction. The situation is life-threatening and the nurse should
intervene immediately with strong systemic bronchodilators, epinephrine, corticosteroids, and oxygen.
A nurse is teaching a client who has a new prescription for PHENYTOIN to treat a seizure disorder. Which
of the following adverse effects should the nurse instruct the client to report IMMEDIATELY to the
provider? ANS: SKIN RASH.
- the nurse should determine that the priority finding is a rash, which can have a measles-like
appearance and progress to exfoliative dermatitis or Stevens-Johnson syndrome. The client should
report this finding to the provider immediately.
A nurse is monitoring a client following a LUMBAR LAMINECTOMY. The client has a drain and indwelling
urinary catheter. The nurse should identify which of the following findings as an indication of a
COMPLICATION of the surgery? ANS: CLEAR DRAINAGE OF DRESSINGS
- This is an indication of a cerebral spinal leak
A nurse is assessing a client who has RIGHT-SIDED HEART FAILURE. Which of the following findings
should the nurse identify as a manifestation of RIGHT- SIDED HEART FAILURE? ANS: INCREASED
ABDOMINAL GIRTH
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have
chronic illnesses. The nurse should identify that which of the following statements by the client indicates
ACCEPTANCE of the role change? ANS: " I changed the floor plan of our homes to accommodate my
father's wheelchair. "
A nurse is caring for a client who is receiving VANCOMYCIN intermittent IV bolus therapy for
METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS. Which of the following findings is an indication to
the nurse that the client is experiencing an ADVERSE EFFECT of the medication? ANS: THE CLIENT IS
BECOMING FLUSHED.
