VATI GREENLIGHT MEDICAL-SURGICAL NURSING &
EMERGENCY CARE EXAM (RN) QUESTIONS COMPLETE
WITH 100% VERIFIED ANSWERS AND RATIONALES
1. A nurse is caring for a client who is 2 hours postoperative following a total
knee arthroplasty. Which of the following findings should the nurse report to
the provider immediately?
Pain level of 6 on a scale of 0 to 10
Serosanguineous drainage on the dressing
Temperature of 37.5°C (99.5°F)
Oxygen saturation of 88% on room air
Correct Answer: Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates hypoxemia and may suggest
pulmonary embolism or atelectasis, which are life-threatening complications after
joint replacement surgery.
2. A nurse is collecting data from a client who has diabetes mellitus and reports
feeling shaky and diaphoretic. Which of the following actions should the nurse
take first?
Give the client 4 ounces of orange juice
Check the client's blood glucose level
Administer glucagon intramuscularly
Notify the provider of the client's symptoms
Correct Answer: Check the client's blood glucose level
,Rationale: The first action is to assess the blood glucose level to confirm
hypoglycemia before treatment. Signs include shakiness, diaphoresis, and
confusion.
3. A nurse is caring for a client who has a chest tube connected to a water-seal
drainage system. Which of the following findings indicates that the chest tube is
functioning properly?
Continuous bubbling in the water-seal chamber
Fluctuation (tidaling) in the water-seal chamber with inspiration
Constant bubbling in the suction control chamber
No drainage in the collection chamber for 4 hours
Correct Answer: Fluctuation (tidaling) in the water-seal chamber with inspiration
Rationale: Tidaling (rising and falling of fluid in the water-seal chamber with
inspiration and expiration) indicates that the chest tube is patent and functioning
properly.
4. A nurse is reinforcing teaching with a client who has a new diagnosis of type 2
diabetes mellitus. Which of the following statements by the client indicates
understanding of the teaching?
I will check my blood glucose level once per week
I will take my metformin only when I eat a large meal
I can stop my medication when my blood sugar is normal
I will rotate my insulin injection sites if I use insulin
Correct Answer: I will rotate my insulin injection sites if I use insulin
Rationale: Rotating insulin injection sites prevents lipodystrophy (fatty tissue
changes) and promotes consistent absorption of insulin.
5. A nurse is caring for a client who has a pulmonary embolism. Which of the
following findings should the nurse expect?
,Bradycardia and hypotension
Chest pain and hemoptysis
Hypothermia and bradypnea
Bounding pulses and polyuria
Correct Answer: Chest pain and hemoptysis
Rationale: Pulmonary embolism typically presents with sudden chest pain,
dyspnea, hemoptysis, tachypnea, tachycardia, and anxiety.
6. A nurse is collecting data from a client who has chronic obstructive pulmonary
disease (COPD). Which of the following findings should the nurse expect to
observe?
Clubbing of the fingers
Flattened neck veins
Decreased anteroposterior chest diameter
Pink, moist skin
Correct Answer: Clubbing of the fingers
Rationale: Clubbing (enlargement of the fingertips) is a late sign of chronic
hypoxemia seen in COPD and other chronic lung diseases.
7. A nurse is reinforcing teaching with a client who has a new colostomy. Which
of the following statements by the client indicates understanding of the
teaching?
I will change my ostomy appliance every day
I will restrict my fluid intake to reduce output
I will empty my pouch when it is one-third to one-half full
I will use alcohol to clean the skin around my stoma
Correct Answer: I will empty my pouch when it is one-third to one-half full
, Rationale: Emptying the pouch when it is one-third to one-half full prevents
leakage, skin breakdown, and pouch detachment due to excess weight.
8. A nurse is caring for a client who has a nasogastric tube connected to low
intermittent suction. Which of the following findings should indicate to the
nurse that the tube may be displaced?
Greenish-yellow drainage in the collection canister
The client reports a sore throat
The pH of aspirated fluid is 4.0
The client reports nausea and abdominal distention
Correct Answer: The client reports nausea and abdominal distention
Rationale: Nausea and abdominal distention may indicate that the NG tube is not
functioning properly or is displaced, leading to accumulation of gastric contents.
9. A nurse is collecting data from a client who has heart failure and is receiving
furosemide. Which of the following findings indicates that the medication is
having a therapeutic effect?
Weight loss of 1 kg in 24 hours
Heart rate of 110 beats per minute
Blood pressure of 150/90 mm Hg
Respiratory rate of 28 breaths per minute
Correct Answer: Weight loss of 1 kg in 24 hours
Rationale: Weight loss of 1 kg (2.2 lbs) in 24 hours represents diuresis (fluid loss),
indicating that furosemide is effectively reducing fluid overload.
10. A nurse is caring for a client who has a new diagnosis of deep vein
thrombosis (DVT) of the left lower leg. Which of the following actions should the
nurse take first?
Apply warm compresses to the affected leg
EMERGENCY CARE EXAM (RN) QUESTIONS COMPLETE
WITH 100% VERIFIED ANSWERS AND RATIONALES
1. A nurse is caring for a client who is 2 hours postoperative following a total
knee arthroplasty. Which of the following findings should the nurse report to
the provider immediately?
Pain level of 6 on a scale of 0 to 10
Serosanguineous drainage on the dressing
Temperature of 37.5°C (99.5°F)
Oxygen saturation of 88% on room air
Correct Answer: Oxygen saturation of 88% on room air
Rationale: An oxygen saturation of 88% indicates hypoxemia and may suggest
pulmonary embolism or atelectasis, which are life-threatening complications after
joint replacement surgery.
2. A nurse is collecting data from a client who has diabetes mellitus and reports
feeling shaky and diaphoretic. Which of the following actions should the nurse
take first?
Give the client 4 ounces of orange juice
Check the client's blood glucose level
Administer glucagon intramuscularly
Notify the provider of the client's symptoms
Correct Answer: Check the client's blood glucose level
,Rationale: The first action is to assess the blood glucose level to confirm
hypoglycemia before treatment. Signs include shakiness, diaphoresis, and
confusion.
3. A nurse is caring for a client who has a chest tube connected to a water-seal
drainage system. Which of the following findings indicates that the chest tube is
functioning properly?
Continuous bubbling in the water-seal chamber
Fluctuation (tidaling) in the water-seal chamber with inspiration
Constant bubbling in the suction control chamber
No drainage in the collection chamber for 4 hours
Correct Answer: Fluctuation (tidaling) in the water-seal chamber with inspiration
Rationale: Tidaling (rising and falling of fluid in the water-seal chamber with
inspiration and expiration) indicates that the chest tube is patent and functioning
properly.
4. A nurse is reinforcing teaching with a client who has a new diagnosis of type 2
diabetes mellitus. Which of the following statements by the client indicates
understanding of the teaching?
I will check my blood glucose level once per week
I will take my metformin only when I eat a large meal
I can stop my medication when my blood sugar is normal
I will rotate my insulin injection sites if I use insulin
Correct Answer: I will rotate my insulin injection sites if I use insulin
Rationale: Rotating insulin injection sites prevents lipodystrophy (fatty tissue
changes) and promotes consistent absorption of insulin.
5. A nurse is caring for a client who has a pulmonary embolism. Which of the
following findings should the nurse expect?
,Bradycardia and hypotension
Chest pain and hemoptysis
Hypothermia and bradypnea
Bounding pulses and polyuria
Correct Answer: Chest pain and hemoptysis
Rationale: Pulmonary embolism typically presents with sudden chest pain,
dyspnea, hemoptysis, tachypnea, tachycardia, and anxiety.
6. A nurse is collecting data from a client who has chronic obstructive pulmonary
disease (COPD). Which of the following findings should the nurse expect to
observe?
Clubbing of the fingers
Flattened neck veins
Decreased anteroposterior chest diameter
Pink, moist skin
Correct Answer: Clubbing of the fingers
Rationale: Clubbing (enlargement of the fingertips) is a late sign of chronic
hypoxemia seen in COPD and other chronic lung diseases.
7. A nurse is reinforcing teaching with a client who has a new colostomy. Which
of the following statements by the client indicates understanding of the
teaching?
I will change my ostomy appliance every day
I will restrict my fluid intake to reduce output
I will empty my pouch when it is one-third to one-half full
I will use alcohol to clean the skin around my stoma
Correct Answer: I will empty my pouch when it is one-third to one-half full
, Rationale: Emptying the pouch when it is one-third to one-half full prevents
leakage, skin breakdown, and pouch detachment due to excess weight.
8. A nurse is caring for a client who has a nasogastric tube connected to low
intermittent suction. Which of the following findings should indicate to the
nurse that the tube may be displaced?
Greenish-yellow drainage in the collection canister
The client reports a sore throat
The pH of aspirated fluid is 4.0
The client reports nausea and abdominal distention
Correct Answer: The client reports nausea and abdominal distention
Rationale: Nausea and abdominal distention may indicate that the NG tube is not
functioning properly or is displaced, leading to accumulation of gastric contents.
9. A nurse is collecting data from a client who has heart failure and is receiving
furosemide. Which of the following findings indicates that the medication is
having a therapeutic effect?
Weight loss of 1 kg in 24 hours
Heart rate of 110 beats per minute
Blood pressure of 150/90 mm Hg
Respiratory rate of 28 breaths per minute
Correct Answer: Weight loss of 1 kg in 24 hours
Rationale: Weight loss of 1 kg (2.2 lbs) in 24 hours represents diuresis (fluid loss),
indicating that furosemide is effectively reducing fluid overload.
10. A nurse is caring for a client who has a new diagnosis of deep vein
thrombosis (DVT) of the left lower leg. Which of the following actions should the
nurse take first?
Apply warm compresses to the affected leg
