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VATI Med-Surg pre-assessment with 100% correct answers 2024
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A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply.) A. Dyspnea B. Gastrointestinal bloating C. Jugular vein distention D. Confu...

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  • April 28, 2024
  • 16
  • 2023/2024
  • Exam (elaborations)
  • Questions & answers

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  • vati med surg pre assessment

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  • VATI
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VATI Med-Surg pre-assessment with
100% correct answers 2024




A nurse is preparing to administer a transfusion of RBCs to a client who has heart
failure. For which of the following manifestations should the nurse monitor to prevent
fluid volume overload? (Select all that apply.)

A. Dyspnea
B. Gastrointestinal bloating
C. Jugular vein distention
D. Confusion
E. Hypotension - correct answer A. Dyspnea
C. Jugular vein distention
D. Confusion

Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein distention
is a clinical manifestation of fluid volume overload. Confusion is a clinical
manifestation of fluid volume overload.

A nurse is caring for a client who has a spinal cord injury and suspects the client is
developing autonomic dysreflexia. Which of the following actions should the nurse
take first?

A. Check the client for a fecal impaction.
B. Examine the client for areas of skin breakdown.
C. Check the client's bladder for distention.
D. Place the client in a sitting position. - correct answer D. Place the client in a sitting
position.

The nurse should use the least invasive intervention first. Therefore, the nurse
should place the client in a sitting position to decrease the manifestation of
hypertension.

The nurse might have to check the client for fecal impaction, which can precipitate
autonomic dysreflexia. However, the nurse should use a less invasive intervention
first. The nurse might have to examine the client's skin for areas of skin breakdown
or pressure, which can trigger autonomic dysreflexia. However, the nurse should use
a less invasive intervention first. The nurse might have to check the client for bladder
distention, which can precipitate autonomic dysreflexia. However, the nurse should
use a less invasive intervention first.

,VATI Med-Surg pre-assessment with
100% correct answers 2024




A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for
clients who have surgical incisions. Which of the following factors should the nurse
include in the teaching? (Select all that apply.)

A. Poor nutritional state
B. Altered mental status
C. Obesity
D. Pain medication administration
E. Wound infection - correct answer A. Poor nutritional state
C. Obesity
E. Wound infection

A nurse is caring for a client who has an endotracheal tube and is receiving
mechanical ventilation. Which of the following interventions should the nurse take to
reduce the risk for ventilator-associated pneumonia?

A. Position the head of the client's bed in the flat position.
B. Turn the client every 4 hr.
C. Rinse the client's mouth with an antimicrobial solution every 4 hr.
D. Perform hand hygiene prior to suctioning the client's endotracheal tube. - correct
answer C. Rinse the client's mouth with an antimicrobial solution every 4 hr.

The nurse should brush the client's teeth every 8 hr and rinse the client's mouth with
an antimicrobial rinse every 2 hr to reduce the growth of bacteria.

The nurse should elevate the head of the client's bed 30° to reduce the risk for
aspiration and pneumonia. The nurse should turn the client every 2 hr to promote
lung expansion and reduce the risk for pneumonia. The nurse should perform hand
hygiene prior to suctioning the client's endotracheal tube to reduce the risk of
introducing bacteria.

A nurse is providing instruction to a new nurse about caring for clients who are
receiving diuretic therapy to treat heart failure. The nurse should explain that which
of the following medications puts clients at risk for both hyperkalemia and
hyponatremia?

A. Furosemide
B. Hydrochlorothiazide
C. Metolazone

, VATI Med-Surg pre-assessment with
100% correct answers 2024




D. Spironolactone - correct answer D. Spironolactone

Spironolactone is a potassium-sparing diuretic. It blocks the effects of aldosterone in
the renal tubules, causing a loss of sodium and water and the retention of potassium.
The possible adverse reactions include hyperkalemia and hyponatremia.

Furosemide is a high-ceiling (loop) diuretic that increases the risk of hyponatremia
and hypokalemia, not hyperkalemia. Hydrochlorothiazide is a thiazide diuretic that
increases the risk of hypokalemia, not hyperkalemia. Metolazone is a thiazide
diuretic that increases the risk of hyponatremia and hypokalemia, not hyperkalemia.

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of
the following findings should the nurse recognize as a risk factor for this medication?

A. History of bulimia
B. History of NSAID use
C. Drinks green tea
D. Has a glass of wine with dinner each day - correct answer B. History of NSAID
use

The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic
ulcer disease. NSAIDs break down the mucosal barrier and cause production of
prostaglandins to decrease, which results in local gastric mucosal injury.

A nurse is planning care for a client following a cardiac catheterization accessed
through his femoral artery. Which of the following actions should the plan to take?

A. Instruct the client to perform range-of-motion exercises to his lower extremities.
B. Perform neurovascular checks with vital signs.
C. Ambulate the client 1 hr following the procedure.
D. Restrict the client's fluid intake. - correct answer B. Perform neurovascular checks
with vital signs.

The nurse should assess color, temperature, and pulse in the affected extremity and
monitor the client for neurovascular changes that can indicate a stroke, such as
slurred speech and visual disturbances.

The client should keep the extremity of the insertion site straight to reduce the risk
for bleeding. A knee brace might be used to restrict movement. The client should

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