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RN VATI ADULT MEDICAL SURGICAL LATEST 2024 GRADED 100% A+ WITH NGN
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RN VATI ADULT MEDICAL SURGICAL LATEST 2024 GRADED 100% A+ WITH NGN
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RN VATI ADULT MEDICAL SURGICAL LATEST 2024 GRADED100% A+ WITH NGN
A nurse is caring for a client with congestive heart failure who is experiencing dyspnea.
Which of the following interventions should the nurse implement first?
A. Administer a prescribed bronchodilator. B. Place the client in high Fowler’s position. C.
Obtain the client’s vital signs. D. Auscultate lung sounds.
Answer: B. Place the client in high Fowler’s position.
Rationale: Placing the client in high Fowler's position helps to decrease venous return to the
heart and reduces pulmonary congestion, improving breathing.
Question 2:
A client with type 2 diabetes mellitus reports feeling shaky and sweaty. The nurse checks
the client’s blood glucose level and finds it to be 55 mg/dL. Which of the following actions
should the nurse take first?
A. Administer 50% dextrose IV. B. Give the client 4 oz of orange juice. C. Recheck the blood
glucose level in 15 minutes. D. Notify the healthcare provider.
Answer: B. Give the client 4 oz of orange juice.
Rationale: Providing a quick source of glucose, such as orange juice, is the initial intervention
for hypoglycemia to rapidly increase blood glucose levels.
Question 3:
A nurse is assessing a client who has right-sided heart failure. Which of the following
findings should the nurse expect?
A. Bilateral crackles in the lungs. B. Jugular vein distention. C. Dry, warm skin. D. Frequent
urination.
Answer: B. Jugular vein distention.
Rationale: Right-sided heart failure often leads to systemic venous congestion, resulting in
jugular vein distention.
Question 4:
,A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client.
Which of the following actions is essential to prevent a transfusion reaction?
A. Warm the PRBCs before transfusion. B. Administer the transfusion over 8 hours. C. Verify
the client’s identification and blood compatibility. D. Monitor the client’s blood pressure every
15 minutes during the transfusion.
Answer: C. Verify the client’s identification and blood compatibility.
Rationale: Verifying the client’s identification and ensuring blood compatibility are critical
steps to prevent transfusion reactions.
Question 5:
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which
of the following actions should the nurse take to prevent dislocation of the prosthesis?
A. Place the client in a low Fowler’s position. B. Position a pillow between the client’s legs. C.
Turn the client onto the operative side. D. Keep the hip adducted when turning the client.
Answer: B. Position a pillow between the client’s legs.
Rationale: Placing a pillow between the client’s legs helps to maintain proper alignment and
prevent dislocation of the hip prosthesis.
Question 6:
A client with chronic kidney disease is scheduled for hemodialysis. The nurse notes that the
client’s last dialysis was three days ago. Which of the following findings should the nurse
expect?
A. Hypokalemia. B. Hypotension. C. Weight loss. D. Elevated serum creatinine.
Answer: D. Elevated serum creatinine.
Rationale: With chronic kidney disease and delayed hemodialysis, the client’s serum creatinine
levels are likely to be elevated due to decreased renal clearance.
Question 7:
A nurse is caring for a client who has a prescription for enoxaparin. Which of the following
actions should the nurse take?
A. Administer the medication into the deltoid muscle. B. Aspirate before injecting the
medication. C. Massage the injection site after administration. D. Inject the medication into the
subcutaneous tissue.
,Answer: D. Inject the medication into the subcutaneous tissue.
Rationale: Enoxaparin should be administered subcutaneously to ensure proper absorption and
therapeutic effect.
Question 8:
A nurse is assessing a client who has a suspected myocardial infarction. Which of the
following findings is the priority to report to the provider?
A. Nausea and vomiting. B. Blood pressure 160/90 mm Hg. C. Tachycardia. D. New onset of
confusion.
Answer: D. New onset of confusion.
Rationale: New onset of confusion could indicate decreased cerebral perfusion, which is a
priority finding and requires immediate intervention.
Question 9:
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of
the following actions should the nurse take?
A. Obtain a daily weight. B. Change the TPN tubing every 72 hours. C. Monitor urine specific
gravity every 4 hours. D. Administer TPN through a peripheral IV line.
Answer: A. Obtain a daily weight.
Rationale: Monitoring daily weight helps to assess fluid balance and nutritional status in clients
receiving TPN.
Question 10:
A client who is postoperative following abdominal surgery reports feeling something "give
way" in the surgical incision. The nurse notes the presence of a loop of bowel protruding
through the incision. Which of the following actions should the nurse take first?
A. Place the client in a supine position. B. Cover the wound with a sterile, saline-moistened
dressing. C. Apply an abdominal binder. D. Notify the healthcare provider.
Answer: B. Cover the wound with a sterile, saline-moistened dressing.
Rationale: Covering the wound with a sterile, saline-moistened dressing protects the bowel and
reduces the risk of infection and further injury.
, Question 11:
A nurse is providing discharge teaching to a client who has a new diagnosis of peptic ulcer
disease. Which of the following instructions should the nurse include?
A. "Take NSAIDs for pain relief." B. "Eat a high-protein, low-carbohydrate diet." C. "Avoid
drinking alcohol." D. "Increase your intake of dairy products."
Answer: C. "Avoid drinking alcohol."
Rationale: Alcohol can irritate the stomach lining and exacerbate peptic ulcer disease.
Question 12:
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy.
Which of the following oxygen delivery systems should the nurse use to provide the highest
concentration of oxygen?
A. Nasal cannula. B. Simple face mask. C. Non-rebreather mask. D. Venturi mask.
Answer: C. Non-rebreather mask.
Rationale: A non-rebreather mask delivers the highest concentration of oxygen without
intubation.
Question 13:
A nurse is caring for a client with hyperthyroidism. Which of the following findings should
the nurse expect?
A. Cold intolerance. B. Bradycardia. C. Weight loss. D. Constipation.
Answer: C. Weight loss.
Rationale: Hyperthyroidism increases metabolism, leading to weight loss.
Question 14:
A client is admitted with suspected meningitis. Which of the following actions should the
nurse take first?
A. Administer antibiotics. B. Obtain a blood culture. C. Perform a lumbar puncture. D. Place the
client in isolation.
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