MEDSURG VATI ASSESSMENT 90
EXAM QUESTIONS WITH CORRECT
ANSWERS
A nurse is assisting with the care of four clients. Which of the following
|| || || || || || || || || || || || || ||
clients is the priority for
|| || || ||
the nurse to see
|| || ||
-A client who has chest tubes and an oxygen Sat of 90%
|| || || || || || || || || || ||
- aclient who has peripheral edema and urinary output of 130 over 4hrs
|| || || || || || || || || || || ||
- A client who has a permanent pacemaker with heart rate of 76/min
|| || || || || || || || || || || ||
-a client who has pericarditis and temp. 38 c 100.4 - CORRECT ANSWER✔✔--
|| || || || || || || || || || || ||
A client who has chest tubes and an oxygen Sat of 90%
|| || || || || || || || || || || ||
Using the airway, breathing, and circulation approach to client care, the
|| || || || || || || || || || ||
nurse should determine that the priority finding is the client's oxygen
|| || || || || || || || || || ||
saturation level, which is below the expected reference range of 95% to
|| || || || || || || || || || || ||
100%. Therefore, the nurse should attend to this client first.
|| || || || || || || || ||
A nurse is collecting data from a client who was admitted with a Glasgow
|| || || || || || || || || || || || || ||
Coma Scale of 3. Which
|| || || ||
of the following findings should the nurse expect?
|| || || || || || ||
- Vacalizes sound
|| ||
-Blinks eyes when asked || || ||
-Follows motor commands || ||
,-Nonresponsive Commands - CORRECT ANSWER✔✔-Nonresponsive Commands || || || || ||
A client who has a GCS of less than 8 has evidence of severe head injury
|| || || || || || || || || || || || || || || ||
and is in a comatose state. The GCS is a standardized tool that allows for
|| || || || || || || || || || || || || || ||
the evaluation of a client's level of consciousness. The test is divided into
|| || || || || || || || || || || || ||
three sections that evaluate eye opening, motor response, and verbal
|| || || || || || || || || ||
response. The GCS ranges from a high score of 15 (fully alert) to a low score
|| || || || || || || || || || || || || || ||
of 3 (fully comatose).
|| || || ||
A nurse is monitoring a client who has a pneumothorax and a chest tube in
|| || || || || || || || || || || || || || ||
place with a closed chest drainage system connected to low suction. For
|| || || || || || || || || || || ||
which of the following findings should the nurse notify the charge nurse
|| || || || || || || || || || ||
- Fluctation of the water level in the water seal chamber
|| || || || || || || || || ||
-constant bubling in the suction control chamber
|| || || || || ||
- periodic bubbling in the water seal chamber
|| || || || || || ||
- Persistent bubbling in the water seal chamber - CORRECT ANSWER✔✔--
|| || || || || || || || || || ||
Persistent bubbling in the water seal chamber || || || || || ||
Excessive and persistent bubbling in the water-seal chamber indicates an air
|| || || || || || || || || || ||
leak in the drainage system. The nurse should notify the charge nurse of this
|| || || || || || || || || || || || ||
finding.
||
A nurse is reinforcing teaching with a male client who has right sided
|| || || || || || || || || || || || ||
hemiparesis about ||
preforming ADL's. Which of the following instructions should the nurse
|| || || || || || || || || ||
include in the teaching || || ||
,-Comb your hair with the unaffected arm
|| || || || || ||
-Dress your unaffected side first
|| || || ||
choose clothing with buttons
|| || ||
-shave with your affected side - CORRECT ANSWER✔✔-Comb your hair with
|| || || || || || || || || || ||
the unaffected arm
|| ||
The nurse should instruct the client to brush their hair with the unaffected
|| || || || || || || || || || || || ||
arm to reduce frustration and increase independence and self-esteem.
|| || || || || || || ||
A nurse is collecting data from a client and auscultates intermittent high-
|| || || || || || || || || || ||
pitched sounds during inspiration over the lower base of the lungs. The
|| || || || || || || || || || || ||
nurse should identify this finding as which of the following lungs sounds
|| || || || || || || || || || ||
- Fine crackles
|| ||
-stridor
-rhonchi
-friction - CORRECT ANSWER✔✔-- Fine crackles
|| || || || ||
Fine crackles are auscultated in the base of the lungs as air moves through
|| || || || || || || || || || || || || ||
airway secretions. Fine crackles are intermittent, high-pitched sounds heard
|| || || || || || || || ||
more often during inspiration.
|| || ||
A nurse is collecting data from a client who has coronary artery disease.
|| || || || || || || || || || || || ||
Which of the following|| || ||
manifestations should the nurse identify as an indication that the client has
|| || || || || || || || || || || ||
angina ( SatA) || ||
, - Chest Discomfort Radiated
|| || ||
- Pain lasting less that 15mins
|| || || || ||
- Pain that is relieved with rest - CORRECT ANSWER✔✔-- Chest Discomfort
|| || || || || || || || || || || ||
Radiated
- Pain lasting less that 15mins
|| || || || ||
- Pain that is relieved with res
|| || || || || ||
A nurse is receiving change-of-shift report for a group of clients. Which of
|| || || || || || || || || || || || ||
the following clients
|| ||
should the nurse plan to see first?
|| || || || || ||
- A client who has diabetes mellitus with diaphoretic - CORRECT
|| || || || || || || || || || ||
ANSWER✔✔-A client who has diabetes mellitus with diaphoretic
|| || || || || || ||
When using the urgent vs. nonurgent approach to client care, the nurse
|| || || || || || || || || || || ||
should determine that the priority action is to attend to a client who has
|| || || || || || || || || || || || || ||
diabetes mellitus and is diaphoretic. Diaphoresis is a manifestation of
|| || || || || || || || || ||
hypoglycemia and can lead to decreased cerebral function. The nurse should
|| || || || || || || || || || ||
check the client's blood glucose and administer a fast-acting glucose as
|| || || || || || || || || || ||
prescribed.
A nurse is collecting data from a client who has tuberculosis and started
|| || || || || || || || || || || || ||
combination therapy ||
2months ago. Which of the following diagnostic results indicates that the
|| || || || || || || || || || ||
client is adhering to the
|| || || ||
medication regimen. ||
- A negative chest X-ray
|| || || ||
EXAM QUESTIONS WITH CORRECT
ANSWERS
A nurse is assisting with the care of four clients. Which of the following
|| || || || || || || || || || || || || ||
clients is the priority for
|| || || ||
the nurse to see
|| || ||
-A client who has chest tubes and an oxygen Sat of 90%
|| || || || || || || || || || ||
- aclient who has peripheral edema and urinary output of 130 over 4hrs
|| || || || || || || || || || || ||
- A client who has a permanent pacemaker with heart rate of 76/min
|| || || || || || || || || || || ||
-a client who has pericarditis and temp. 38 c 100.4 - CORRECT ANSWER✔✔--
|| || || || || || || || || || || ||
A client who has chest tubes and an oxygen Sat of 90%
|| || || || || || || || || || || ||
Using the airway, breathing, and circulation approach to client care, the
|| || || || || || || || || || ||
nurse should determine that the priority finding is the client's oxygen
|| || || || || || || || || || ||
saturation level, which is below the expected reference range of 95% to
|| || || || || || || || || || || ||
100%. Therefore, the nurse should attend to this client first.
|| || || || || || || || ||
A nurse is collecting data from a client who was admitted with a Glasgow
|| || || || || || || || || || || || || ||
Coma Scale of 3. Which
|| || || ||
of the following findings should the nurse expect?
|| || || || || || ||
- Vacalizes sound
|| ||
-Blinks eyes when asked || || ||
-Follows motor commands || ||
,-Nonresponsive Commands - CORRECT ANSWER✔✔-Nonresponsive Commands || || || || ||
A client who has a GCS of less than 8 has evidence of severe head injury
|| || || || || || || || || || || || || || || ||
and is in a comatose state. The GCS is a standardized tool that allows for
|| || || || || || || || || || || || || || ||
the evaluation of a client's level of consciousness. The test is divided into
|| || || || || || || || || || || || ||
three sections that evaluate eye opening, motor response, and verbal
|| || || || || || || || || ||
response. The GCS ranges from a high score of 15 (fully alert) to a low score
|| || || || || || || || || || || || || || ||
of 3 (fully comatose).
|| || || ||
A nurse is monitoring a client who has a pneumothorax and a chest tube in
|| || || || || || || || || || || || || || ||
place with a closed chest drainage system connected to low suction. For
|| || || || || || || || || || || ||
which of the following findings should the nurse notify the charge nurse
|| || || || || || || || || || ||
- Fluctation of the water level in the water seal chamber
|| || || || || || || || || ||
-constant bubling in the suction control chamber
|| || || || || ||
- periodic bubbling in the water seal chamber
|| || || || || || ||
- Persistent bubbling in the water seal chamber - CORRECT ANSWER✔✔--
|| || || || || || || || || || ||
Persistent bubbling in the water seal chamber || || || || || ||
Excessive and persistent bubbling in the water-seal chamber indicates an air
|| || || || || || || || || || ||
leak in the drainage system. The nurse should notify the charge nurse of this
|| || || || || || || || || || || || ||
finding.
||
A nurse is reinforcing teaching with a male client who has right sided
|| || || || || || || || || || || || ||
hemiparesis about ||
preforming ADL's. Which of the following instructions should the nurse
|| || || || || || || || || ||
include in the teaching || || ||
,-Comb your hair with the unaffected arm
|| || || || || ||
-Dress your unaffected side first
|| || || ||
choose clothing with buttons
|| || ||
-shave with your affected side - CORRECT ANSWER✔✔-Comb your hair with
|| || || || || || || || || || ||
the unaffected arm
|| ||
The nurse should instruct the client to brush their hair with the unaffected
|| || || || || || || || || || || || ||
arm to reduce frustration and increase independence and self-esteem.
|| || || || || || || ||
A nurse is collecting data from a client and auscultates intermittent high-
|| || || || || || || || || || ||
pitched sounds during inspiration over the lower base of the lungs. The
|| || || || || || || || || || || ||
nurse should identify this finding as which of the following lungs sounds
|| || || || || || || || || || ||
- Fine crackles
|| ||
-stridor
-rhonchi
-friction - CORRECT ANSWER✔✔-- Fine crackles
|| || || || ||
Fine crackles are auscultated in the base of the lungs as air moves through
|| || || || || || || || || || || || || ||
airway secretions. Fine crackles are intermittent, high-pitched sounds heard
|| || || || || || || || ||
more often during inspiration.
|| || ||
A nurse is collecting data from a client who has coronary artery disease.
|| || || || || || || || || || || || ||
Which of the following|| || ||
manifestations should the nurse identify as an indication that the client has
|| || || || || || || || || || || ||
angina ( SatA) || ||
, - Chest Discomfort Radiated
|| || ||
- Pain lasting less that 15mins
|| || || || ||
- Pain that is relieved with rest - CORRECT ANSWER✔✔-- Chest Discomfort
|| || || || || || || || || || || ||
Radiated
- Pain lasting less that 15mins
|| || || || ||
- Pain that is relieved with res
|| || || || || ||
A nurse is receiving change-of-shift report for a group of clients. Which of
|| || || || || || || || || || || || ||
the following clients
|| ||
should the nurse plan to see first?
|| || || || || ||
- A client who has diabetes mellitus with diaphoretic - CORRECT
|| || || || || || || || || || ||
ANSWER✔✔-A client who has diabetes mellitus with diaphoretic
|| || || || || || ||
When using the urgent vs. nonurgent approach to client care, the nurse
|| || || || || || || || || || || ||
should determine that the priority action is to attend to a client who has
|| || || || || || || || || || || || || ||
diabetes mellitus and is diaphoretic. Diaphoresis is a manifestation of
|| || || || || || || || || ||
hypoglycemia and can lead to decreased cerebral function. The nurse should
|| || || || || || || || || || ||
check the client's blood glucose and administer a fast-acting glucose as
|| || || || || || || || || || ||
prescribed.
A nurse is collecting data from a client who has tuberculosis and started
|| || || || || || || || || || || || ||
combination therapy ||
2months ago. Which of the following diagnostic results indicates that the
|| || || || || || || || || || ||
client is adhering to the
|| || || ||
medication regimen. ||
- A negative chest X-ray
|| || || ||
