RN VATI ADULT MEDICAL SURGICAL 2019 & 2023 TEST
BANK 400 QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES (EVERYTHING ON VATI ADULT
MEDICAL SURGICAL) |ALREADY GRADED A+|BRAND NEW
2023!!!
A nurse is caring for a client who has an NG tube to suction and is receiving IV
fluids to maintain fluid volume balance. Which of the following findings should
indicate to the nurse that this therapy is effective? – ANSWER- Hematocrit 46%
A nurse is analyzing the ABG results of a client who is in respiratory acidosis.
Which of the following mechanisms should the nurse identify as responsible for
this acid-base imbalance? – ANSWER- Retention of carbon dioxide
A nurse is caring for a client who is hemorrhaging and hypotensive from
esophageal variceal bleeding. Which of the following actions should the nurse take
first? – ANSWER- Verify that the client has adequate IV access.
A nurse is caring for a client who is receiving vancomycin intermittent IV bolus
therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the
following findings is an indication to the nurse that the client is experiencing an
adverse effect of the medication? – ANSWER- The client is becoming flushed.
A nurse is caring for a client immediately following intubation with an
endotracheal (ET) tube. Which of the following methods should the nurse identify
as the most reliable for verifying placement of the ET tube? – ANSWER- Check
for end-tidal carbon dioxide levels.
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? – ANSWER- Refractory hypoxemia
A nurse is providing preoperative teaching about stool consistency to a client who
will undergo a colectomy with the placement of an ileostomy. Which of the
following information about stool consistency should the nurse include in the
teaching? – ANSWER- The stool will have a high volume of liquid.
A nurse is assessing a client who has a chest tube connected to a closed water-seal
drainage system. Which of the following findings should the nurse report to the
provider? – ANSWER- Constant bubbling in the water seal chamber
A nurse is caring for a client who has multiple leg fractures and is 24 hr
postoperative following placement of skeletal traction. Which of the following
actions should the nurse take? – ANSWER- Inspect the pin sites at least every 8 hr.
A nurse is caring for a client who is receiving mechanical ventilation. Which of the
following actions should the nurse implement to decrease the client’s risk for
ventilator-associated pneumonia (VAP)? (Select all that apply.) – ANSWERMonitor oral secretions q2hr
Provide oral care q2hr
Asses daily for readiness of extubation
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? – ANSWER- Skin rash
A nurse is assessing a client who recently had a myocardial infarction. Which of
the following findings indicates that the client might be developing pulmonary
edema? (Select all that apply.) – ANSWER- Pink frothy sputum
tachypnea
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The
nurse should identify which of the following findings as an indication of a
microvascular complication? – ANSWER- Retinopathy
A nurse is teaching a client who is scheduled to receive radioactive iodine therapy
for treatment of hyperthyroidism. Which of the following instructions should the
nurse include in the teaching? – ANSWER- Use disposable utensils for meals.
A nurse is providing discharge teaching about infection control at home for a client
who has tuberculosis. Which of the following statements by the client indicates an
understanding of the teaching? – ANSWER- “I will place my used tissues in a
plastic bag.”
A nurse is providing teaching to a client who has a new prescription for cephalexin
oral suspension. Which of the following statements by the client indicates an
understanding of the teaching? – ANSWER- “I will keep the medication
refrigerated.”
A nurse is caring for a client who is intubated and receiving mechanical ventilation
for heroin toxicity. Which of the following assessments is the nurse’s priority? –
ANSWER- ABGsWhen using the airway, breathing, and circulation (ABC)
approach to client care, the nurse’s priority assessment is to monitor the client’s
ABGs, including respiratory status.
A nurse is assessing a client’s ECG strip and notes an irregular heart rate of 98/min
with no clear P waves. Which of the following cardiac dysrhythmias should the
nurse document? – ANSWER- A fib
A nurse is planning care for a client who is scheduled for surgery and has a latex
allergy. Which of the following actions should the nurse plan to take? – ANSWERPlace monitoring cords and tubes in a stockinette.
A nurse is assessing a client who has suspected appendicitis. Which of the
following manifestations should the nurse expect? (Select all that apply.) –
ANSWER- Elevated WBCRebound tenderness
Anorexia
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? –
ANSWER- “I changed the floor plan of our home to accommodate my father’s
wheelchair.”
A nurse is assessing a client who has an exacerbation of diverticular disease. In
which of the following quadrants should the nurse anticipate the client to be
experiencing abdominal pain? – ANSWER- LLQ
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? – ANSWER- Respiratory
alkalosis
This pH is alkaline (increased) and the PCO2 is decreased, representing alveolar
hyperventilation and resultant respiratory alkalosis.
A nurse is providing teaching to a client who has a new prescription for warfarin.
Which of the following medications should the nurse instruct the client to avoid?
(Select all that apply.) – ANSWER- ASA
naproxen
A nurse is preparing a teaching plan for a client who is starting to receive
hemodialysis for chronic kidney disease. Which of the following instructions
should the nurse include in the teaching? – ANSWER- “Avoid food products that
contain trans-fats.”
A client who receives hemodialysis for chronic kidney disease should avoid foods
that contain saturated and trans fats. Healthier fat sources should be substituted to
reduce cardiovascular and dyslipidemia risks.
nurse in an emergency department is caring for a client who is confused, has a
temperature of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional
heat stroke. Which of the following actions should the nurse take first? –
ANSWER- Administer oxygen using a high-concentration mask.
The first action the nurse should take when using the airway, breathing, and
circulation approach to client care is to ensure that the client has a patent airway
and administer oxygen using a high-concentration mask to promote oxygen
perfusion to vital organs.
A nurse is assessing a client who is undergoing radiation therapy for breast cancer.
Which of the following findings is an indication to the nurse that the client is
experiencing an adverse effect of the therapy? – ANSWER- Skin changes
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? – ANSWERClear drainage on the dressings
A nurse is assessing a client who has hypocalcemia. In which of the following
areas should the nurse tap on the client’s face to detect the presence of Chvostek’s
sign? (You will find hot spots to select in the artwork below. Select only the hot
spot that corresponds to your answer.) – ANSWER- The nurse should tap the
client’s cheek just in front of the ear and below the zygomatic arch. The client who
has hypocalcemia will display a Chvostek’s sign, which is a twitching of the facial
muscle.
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