VATI PN Med-Surg – Real Assessment A+ Graded
Answers
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings
should the nurse expect? (Select all that apply.) - ✔✔Poripheral edema
Hepatomegaly
Abdominal distention
A nurse is caring for a client who has heart failure and a new prescription for furosemide. The nurse
should monitor the client for which of the following adverse effects of the medication? - ✔✔Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing loss. Audiometry is
recommended for clients recelving prolonged IV furosemide.
A nurse is reinforcing teaching with a client who is recovering from severe diarrhea and is ready to
resume eating solid foods. Which of the following food items should the nurse recommend? - ✔✔Yogurt
The nurse should recommend adding yogurt to the diet to provide probiotics and add substance to the
stool, making it more formed. A client who is recovering from diarrhea should consume a diet that is low
in fiber. Taking probiotics can also help restore the natural gastrointestinal flora.
A nurse is monitoring a client who has a new prescription for furosemide for peripheral edema. For
which of the following adverse effects should the nurse monitor? - ✔✔Muscle weakness
Furosemide is a loop diuretic, which is used to treat hypertension and edema. Furosemide can cause
excess excretion of potassium. The nurse should monitor the client for manifestations of hypokalemia
such as nausea, muscle weakness, and spasms.
A nurse is contacting the provider of a client who has heart failure and a potassium level of 3.4 mEq/L.
Which of the following client medications should the nurse expect the provider to withhold? -
✔✔Digoxin
,The nurse should expect the provider to withhold digoxin when the client's potassium level is low to
decrease the client's risk of dysrhythrmias due to digoxin toxicity. Potassium assists in displacing digoxin,
because digoxin binds to potassiurm, and reduces the risk for digoxin toxicity.
A nurse is assisting with the care of a client who has cellulitis and is receiving IV ceftriaxone. During data
collection, the nurse notes the client is flushed and the client reports urticaria. After stopping the IV
infusion, which of the following actions should the nurse take first? - ✔✔Check the client's respirations.
After stopping the IV infusion, the first action the nurse should take when using the airway, breathing,
circulation approach to client care is to count the client's respirations and monitor for dyspnea because
a client experiencing an allergic reaction can progress to anaphylactic shock and death.
A registered nurse (RN) in an acute care facility is caring for a group of clients with the assistance of a
licensed practical nurse (LPN). Which of the following tasks should the RN delegate to the LPN? (Select
all that apply.) - ✔✔Inserting an NG tube
Monitoring an IV infusion
Administering IM medications
A nurse is reinforcing teaching with a young adult client about testicular self-examination. Which of the
following instructions should the nurse include? - ✔✔"Examine your testicles after a warm shower."
After exposure to warm water in a shower or bath, the scrotum relaxes and becomes easy to palpate.
The testicle should feel smooth and round, and the client should report any lumps to his provider.
A nurse is assisting in the planning of a health education class for a group of older adult clients. Which of
the following recommendations should the nurse include? - ✔✔Obtain a pneumococcal immunization
The pneumococcal immunization should be obtained to prevent pneumonia and is generally given at or
near the age of 65, One dose provides lifelong immunity
A nurse is preparing to administer eardrops to an adult client who has otitis media. Which of the
following actions should the nurse plan to take? - ✔✔Warm the bottle by holding it in the palm for 5
min before administration.
, The nurse should plan to warm the bottle of drops slightly by holding it in the palm of the hand or
putting the bottle in a pocket for about 5 min. Administering cold ear drops can cause the client to
experience discomfort or dizziness.
A nurse is reinforcing teaching about the use of an oxygen concentrator in the home for a client who has
end-stage emphysema. Which of the following instructions should the nurse include to promote client
safety? - ✔✔Maintain an electrical backup system.
medical services and the electric company of the The nurse should remind the client to maintain an
electrical backup system to ensure continuity of oxygen therapy. This includes notifying local emergency
use of home oxygen equipment. In the event of power loss, the client should notify 911, the provider,
and the home health care agency.
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral
resection of the prostate. The client has reduced urinary output, red urine, and reports bladder pain.
Which of the following actions should the nurse take first? - ✔✔Increase the flow rate of the irrigation
When providing client care, the nurse should use the least restrictive intervention first; therefore, the
nurse should first increase the flow rate of continuous bladder irrigation to keep the urinary output light
pink or yellow.
A nurse is reinforcing teaching with a newly licensed nurse about enoxaparin. The nurse should include
in the teaching that which of the following medications can interact with enoxaparin? (Select all that
apply.) - ✔✔Clopidogrel
Aspirin
Ginkgo biloba
A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the
nurse expect? - ✔✔Cardiac dysrhythmias
The nurse should monitor the client who has hypokalemia, an electrolyte imbalance, for life-threatening
cardlac dysrhythmilas, abdominal pain, and distention.
Answers
A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings
should the nurse expect? (Select all that apply.) - ✔✔Poripheral edema
Hepatomegaly
Abdominal distention
A nurse is caring for a client who has heart failure and a new prescription for furosemide. The nurse
should monitor the client for which of the following adverse effects of the medication? - ✔✔Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing loss. Audiometry is
recommended for clients recelving prolonged IV furosemide.
A nurse is reinforcing teaching with a client who is recovering from severe diarrhea and is ready to
resume eating solid foods. Which of the following food items should the nurse recommend? - ✔✔Yogurt
The nurse should recommend adding yogurt to the diet to provide probiotics and add substance to the
stool, making it more formed. A client who is recovering from diarrhea should consume a diet that is low
in fiber. Taking probiotics can also help restore the natural gastrointestinal flora.
A nurse is monitoring a client who has a new prescription for furosemide for peripheral edema. For
which of the following adverse effects should the nurse monitor? - ✔✔Muscle weakness
Furosemide is a loop diuretic, which is used to treat hypertension and edema. Furosemide can cause
excess excretion of potassium. The nurse should monitor the client for manifestations of hypokalemia
such as nausea, muscle weakness, and spasms.
A nurse is contacting the provider of a client who has heart failure and a potassium level of 3.4 mEq/L.
Which of the following client medications should the nurse expect the provider to withhold? -
✔✔Digoxin
,The nurse should expect the provider to withhold digoxin when the client's potassium level is low to
decrease the client's risk of dysrhythrmias due to digoxin toxicity. Potassium assists in displacing digoxin,
because digoxin binds to potassiurm, and reduces the risk for digoxin toxicity.
A nurse is assisting with the care of a client who has cellulitis and is receiving IV ceftriaxone. During data
collection, the nurse notes the client is flushed and the client reports urticaria. After stopping the IV
infusion, which of the following actions should the nurse take first? - ✔✔Check the client's respirations.
After stopping the IV infusion, the first action the nurse should take when using the airway, breathing,
circulation approach to client care is to count the client's respirations and monitor for dyspnea because
a client experiencing an allergic reaction can progress to anaphylactic shock and death.
A registered nurse (RN) in an acute care facility is caring for a group of clients with the assistance of a
licensed practical nurse (LPN). Which of the following tasks should the RN delegate to the LPN? (Select
all that apply.) - ✔✔Inserting an NG tube
Monitoring an IV infusion
Administering IM medications
A nurse is reinforcing teaching with a young adult client about testicular self-examination. Which of the
following instructions should the nurse include? - ✔✔"Examine your testicles after a warm shower."
After exposure to warm water in a shower or bath, the scrotum relaxes and becomes easy to palpate.
The testicle should feel smooth and round, and the client should report any lumps to his provider.
A nurse is assisting in the planning of a health education class for a group of older adult clients. Which of
the following recommendations should the nurse include? - ✔✔Obtain a pneumococcal immunization
The pneumococcal immunization should be obtained to prevent pneumonia and is generally given at or
near the age of 65, One dose provides lifelong immunity
A nurse is preparing to administer eardrops to an adult client who has otitis media. Which of the
following actions should the nurse plan to take? - ✔✔Warm the bottle by holding it in the palm for 5
min before administration.
, The nurse should plan to warm the bottle of drops slightly by holding it in the palm of the hand or
putting the bottle in a pocket for about 5 min. Administering cold ear drops can cause the client to
experience discomfort or dizziness.
A nurse is reinforcing teaching about the use of an oxygen concentrator in the home for a client who has
end-stage emphysema. Which of the following instructions should the nurse include to promote client
safety? - ✔✔Maintain an electrical backup system.
medical services and the electric company of the The nurse should remind the client to maintain an
electrical backup system to ensure continuity of oxygen therapy. This includes notifying local emergency
use of home oxygen equipment. In the event of power loss, the client should notify 911, the provider,
and the home health care agency.
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral
resection of the prostate. The client has reduced urinary output, red urine, and reports bladder pain.
Which of the following actions should the nurse take first? - ✔✔Increase the flow rate of the irrigation
When providing client care, the nurse should use the least restrictive intervention first; therefore, the
nurse should first increase the flow rate of continuous bladder irrigation to keep the urinary output light
pink or yellow.
A nurse is reinforcing teaching with a newly licensed nurse about enoxaparin. The nurse should include
in the teaching that which of the following medications can interact with enoxaparin? (Select all that
apply.) - ✔✔Clopidogrel
Aspirin
Ginkgo biloba
A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the
nurse expect? - ✔✔Cardiac dysrhythmias
The nurse should monitor the client who has hypokalemia, an electrolyte imbalance, for life-threatening
cardlac dysrhythmilas, abdominal pain, and distention.
