VATI Med-Surg Pre-Assessment Test Questions and Answers Rated A
A nurse is preparing to administer a transfusion of RBCs
to a client who has heart failure. For which of the following A. Dyspnea
manifestations should the nurse monitor to prevent fluid C. Jugular vein distention
volume overload? (Select all that apply.) D. Confusion
A. Dyspnea Dyspnea is a clinical manifestation of fluid volume over-
B. Gastrointestinal bloating load. Jugular vein distention is a clinical manifestation of
C. Jugular vein distention fluid volume overload. Confusion is a clinical manifestation
D. Confusion of fluid volume overload.
E. Hypotension
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
A nurse is caring for a client who has a spinal cord injury
position to decrease the manifestation of hypertension.
and suspects the client is developing autonomic dysre-
flexia. Which of the following actions should the nurse take The nurse might have to check the client for fecal im-
first? paction, which can precipitate autonomic dysreflexia.
However, the nurse should use a less invasive intervention
A. Check the client for a fecal impaction.
first. The nurse might have to examine the client's skin for
B. Examine the client for areas of skin breakdown.
areas of skin breakdown or pressure, which can trigger
C. Check the client's bladder for distention.
autonomic dysreflexia. However, the nurse should use a
D. Place the client in a sitting position.
less invasive intervention first. The nurse might have to
check the client for bladder distention, which can precipi-
tate autonomic dysreflexia. However, the nurse should use
a less invasive intervention first.
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
,VATI Med-Surg Pre-Assessment Test Questions and Answers Rated A
B. Altered mental status
A. Poor nutritional state
C. Obesity
C. Obesity
D. Pain medication administration
E. Wound infection
E. Wound infection
C. Rinse the client's mouth with an antimicrobial solution
every 4 hr.
A nurse is caring for a client who has an endotracheal
tube and is receiving mechanical ventilation. Which of the
The nurse should brush the client's teeth every 8 hr and
following interventions should the nurse take to reduce
rinse the client's mouth with an antimicrobial rinse every
the risk for ventilator-associated pneumonia?
2 hr to reduce the growth of bacteria.
A. Position the head of the client's bed in the flat position.
The nurse should elevate the head of the client's bed
B. Turn the client every 4 hr.
30° to reduce the risk for aspiration and pneumonia. The
C. Rinse the client's mouth with an antimicrobial solution
nurse should turn the client every 2 hr to promote lung
every 4 hr.
expansion and reduce the risk for pneumonia. The nurse
D. Perform hand hygiene prior to suctioning the client's
should perform hand hygiene prior to suctioning the
endotracheal tube.
client's endotracheal tube to reduce the risk of introducing
bacteria.
D. Spironolactone
A nurse is providing instruction to a new nurse about Spironolactone is a potassium-sparing diuretic. It blocks
caring for clients who are receiving diuretic therapy to the ettects of aldosterone in the renal tubules, causing a
treat heart failure. The nurse should explain that which loss of sodium and water and the retention of potassium.
of the following medications puts clients at risk for both The possible adverse reactions include hyperkalemia and
hyperkalemia and hyponatremia? hyponatremia.
A. Furosemide Furosemide is a high-ceiling (loop) diuretic that increases
B. Hydrochlorothiazide the risk of hyponatremia and hypokalemia, not hyper-
C. Metolazone kalemia. Hydrochlorothiazide is a thiazide diuretic that in-
D. Spironolactone creases the risk of hypokalemia, not hyperkalemia. Meto-
lazone is a thiazide diuretic that increases the risk of hy-
ponatremia and hypokalemia, not hyperkalemia.
A nurse is preparing to administer a transfusion of RBCs
to a client who has heart failure. For which of the following A. Dyspnea
manifestations should the nurse monitor to prevent fluid C. Jugular vein distention
volume overload? (Select all that apply.) D. Confusion
A. Dyspnea Dyspnea is a clinical manifestation of fluid volume over-
B. Gastrointestinal bloating load. Jugular vein distention is a clinical manifestation of
C. Jugular vein distention fluid volume overload. Confusion is a clinical manifestation
D. Confusion of fluid volume overload.
E. Hypotension
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
A nurse is caring for a client who has a spinal cord injury
position to decrease the manifestation of hypertension.
and suspects the client is developing autonomic dysre-
flexia. Which of the following actions should the nurse take The nurse might have to check the client for fecal im-
first? paction, which can precipitate autonomic dysreflexia.
However, the nurse should use a less invasive intervention
A. Check the client for a fecal impaction.
first. The nurse might have to examine the client's skin for
B. Examine the client for areas of skin breakdown.
areas of skin breakdown or pressure, which can trigger
C. Check the client's bladder for distention.
autonomic dysreflexia. However, the nurse should use a
D. Place the client in a sitting position.
less invasive intervention first. The nurse might have to
check the client for bladder distention, which can precipi-
tate autonomic dysreflexia. However, the nurse should use
a less invasive intervention first.
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
,VATI Med-Surg Pre-Assessment Test Questions and Answers Rated A
B. Altered mental status
A. Poor nutritional state
C. Obesity
C. Obesity
D. Pain medication administration
E. Wound infection
E. Wound infection
C. Rinse the client's mouth with an antimicrobial solution
every 4 hr.
A nurse is caring for a client who has an endotracheal
tube and is receiving mechanical ventilation. Which of the
The nurse should brush the client's teeth every 8 hr and
following interventions should the nurse take to reduce
rinse the client's mouth with an antimicrobial rinse every
the risk for ventilator-associated pneumonia?
2 hr to reduce the growth of bacteria.
A. Position the head of the client's bed in the flat position.
The nurse should elevate the head of the client's bed
B. Turn the client every 4 hr.
30° to reduce the risk for aspiration and pneumonia. The
C. Rinse the client's mouth with an antimicrobial solution
nurse should turn the client every 2 hr to promote lung
every 4 hr.
expansion and reduce the risk for pneumonia. The nurse
D. Perform hand hygiene prior to suctioning the client's
should perform hand hygiene prior to suctioning the
endotracheal tube.
client's endotracheal tube to reduce the risk of introducing
bacteria.
D. Spironolactone
A nurse is providing instruction to a new nurse about Spironolactone is a potassium-sparing diuretic. It blocks
caring for clients who are receiving diuretic therapy to the ettects of aldosterone in the renal tubules, causing a
treat heart failure. The nurse should explain that which loss of sodium and water and the retention of potassium.
of the following medications puts clients at risk for both The possible adverse reactions include hyperkalemia and
hyperkalemia and hyponatremia? hyponatremia.
A. Furosemide Furosemide is a high-ceiling (loop) diuretic that increases
B. Hydrochlorothiazide the risk of hyponatremia and hypokalemia, not hyper-
C. Metolazone kalemia. Hydrochlorothiazide is a thiazide diuretic that in-
D. Spironolactone creases the risk of hypokalemia, not hyperkalemia. Meto-
lazone is a thiazide diuretic that increases the risk of hy-
ponatremia and hypokalemia, not hyperkalemia.
