MEDSURG VATI ASSESSMENT 90 Q'S 100% CORRECT
ANSWERS /VERIFIED AND UPDATED
1.A nurse is assisting with the care of four clients. Which of the following clients is
the priority for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 130 over 4hrs
- A client who has a permanent pacemaker with heart rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4: - A client who has chest tubes
and an oxygen Sat of 90%
Using the airway, breathing, and circulation approach to client care, the
nurse should determine that the priority finding is the client's oxygen
saturation level, which is below the expected reference range of 95% to
100%. Therefore, the nurse should attend to this client first.
,2.A nurse is collecting data from a client who was admitted with a Glasgow Coma
Scale of 3. Which
of the following findings should the nurse expect?
- Vacalizes sound
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands: Nonresponsive Commands
A client who has a GCS of less than 8 has evidence of severe head
injury and is in a comatose state. The GCS is a standardized tool that
allows for the evaluation of a client's level of consciousness. The test is
divided into three sections that evaluate eye opening, motor response,
and verbal response. The GCS ranges from a high score of 15 (fully
alert) to a low score of 3 (fully comatose).
3.A nurse is monitoring a client who has a pneumothorax and a chest tube in place
with a closed chest drainage system connected to low suction. For which of the
following findings should the nurse notify the charge nurse
- Fluctation of the water level in the water seal chamber
,-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber: - Persistent bubbling in the
water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates
an air leak in the drainage system. The nurse should notify the charge
nurse of this finding.
4.A nurse is reinforcing teaching with a male client who has right sided
hemiparesis about
preforming ADL's. Which of the following instructions should the nurse in-
clude in the teaching
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side: Comb your hair with the unaffected arm
The nurse should instruct the client to brush their hair with the unaffecte
arm to reduce frustration and increase independence and self-esteem.
, 5.A nurse is collecting data from a client and auscultates intermittent
high-pitched sounds during inspiration over the lower base of the lungs. The
nurse should identify this finding as which of the following lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction: - Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves
through airway secretions. Fine crackles are intermittent, high-pitched
sounds heard more often during inspiration.
6.A nurse is collecting data from a client who has coronary artery disease.
Which of the following
manifestations should the nurse identify as an indication that the client has
angina ( SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
ANSWERS /VERIFIED AND UPDATED
1.A nurse is assisting with the care of four clients. Which of the following clients is
the priority for
the nurse to see
-A client who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of 130 over 4hrs
- A client who has a permanent pacemaker with heart rate of 76/min
-a client who has pericarditis and temp. 38 c 100.4: - A client who has chest tubes
and an oxygen Sat of 90%
Using the airway, breathing, and circulation approach to client care, the
nurse should determine that the priority finding is the client's oxygen
saturation level, which is below the expected reference range of 95% to
100%. Therefore, the nurse should attend to this client first.
,2.A nurse is collecting data from a client who was admitted with a Glasgow Coma
Scale of 3. Which
of the following findings should the nurse expect?
- Vacalizes sound
-Blinks eyes when asked
-Follows motor commands
-Nonresponsive Commands: Nonresponsive Commands
A client who has a GCS of less than 8 has evidence of severe head
injury and is in a comatose state. The GCS is a standardized tool that
allows for the evaluation of a client's level of consciousness. The test is
divided into three sections that evaluate eye opening, motor response,
and verbal response. The GCS ranges from a high score of 15 (fully
alert) to a low score of 3 (fully comatose).
3.A nurse is monitoring a client who has a pneumothorax and a chest tube in place
with a closed chest drainage system connected to low suction. For which of the
following findings should the nurse notify the charge nurse
- Fluctation of the water level in the water seal chamber
,-constant bubling in the suction control chamber
- periodic bubbling in the water seal chamber
- Persistent bubbling in the water seal chamber: - Persistent bubbling in the
water seal chamber
Excessive and persistent bubbling in the water-seal chamber indicates
an air leak in the drainage system. The nurse should notify the charge
nurse of this finding.
4.A nurse is reinforcing teaching with a male client who has right sided
hemiparesis about
preforming ADL's. Which of the following instructions should the nurse in-
clude in the teaching
-Comb your hair with the unaffected arm
-Dress your unaffected side first
choose clothing with buttons
-shave with your affected side: Comb your hair with the unaffected arm
The nurse should instruct the client to brush their hair with the unaffecte
arm to reduce frustration and increase independence and self-esteem.
, 5.A nurse is collecting data from a client and auscultates intermittent
high-pitched sounds during inspiration over the lower base of the lungs. The
nurse should identify this finding as which of the following lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction: - Fine crackles
Fine crackles are auscultated in the base of the lungs as air moves
through airway secretions. Fine crackles are intermittent, high-pitched
sounds heard more often during inspiration.
6.A nurse is collecting data from a client who has coronary artery disease.
Which of the following
manifestations should the nurse identify as an indication that the client has
angina ( SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
