MEDSURGVATIASSESSMENTQUESTIONS WITH ANSWERS

MEDSURG VATI ASSESSMENT QUESTIONS WITH
ANSWERS

1. A,.nurse,.is,.assisting,.with,.the,.care,.of,.four,.clients.,.Which,.of,.the,.following,.clients,.i
s,.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
hat,.the,.priority,.finding,.is,.the,.client's,.oxygen,.saturation,.level,,.which,.is,.below,.the,.expected,.refe
nce,.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,.Com
a,.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,.comat
ose,.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,.resp
onse,,.and,.verbal,.response.,.The,.GCS,.ranges,.from,.a,.high,.score,.of,.15,.(fully,.alert),.to,.a,.low,.sco
re,.of,.3,.(fully,.comatose).
1,./,.31

,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,.foll
owing,.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,.charg
e,.nurse,.of,.this,.finding.




4. A,.nurse,.is,.reinforcing,.teaching,.with,.a,.male,.client,.who,.has,.right,.side
d,.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,.clothin
g,.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,.unaffected,.arm,.to,.reduce,.frustr
on,.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,.i
2,./,.31

,dentify,.this,.finding,.as,.which,.of,.the,.following,.lungs,.sounds

- Fine,.crackles




3,./,.31

, -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,.angin
a,.(,.SatA)
- Chest,.Discomfort,.Radiated
- Pain,.lasting,.less,.that,.15mins
- Pain,.that,.is,.relieved,.with,.rest:,.-,.Chest,.Discomfort,.Radiated
- Pain,.lasting,.less,.that,.15mins
- Pain,.that,.is,.relieved,.with,.res
7. A,.nurse,.is,.receiving,.change-of-
shift,.report,.for,.a,.group,.of,.clients.,.Which,.of,.the,.following,.clients
should,.the,.nurse,.plan,.to,.see,.first?
- A,.client,.who,.has,.diabetes,.mellitus,.with,.diaphoretic:,.A,.client,.who,.has,.diabetes,.mellitu
s,.with,.diaphoretic

When,.using,.the,.urgent,.vs.,.nonurgent,.approach,.to,.client,.care,,.the,.nurse,.should




determine,.that,.the,.priority,.action,.is,.to,.attend,.to,.a,.client,.who,.has,.diabetes,.mellitus,.and,.is,.dia
phoretic.,.Diaphoresis,.is,.a,.manifestation,.of,.hypoglycemia,.and,.can,.lead,.to,.decreased,.cerebral
,. function.,.The,.nurse,.should,.check,.the,.client's,.blood,.glucose,.and,.administer,.a,.fast-
,. acting,.glucose,.as,.prescribed.
8. A,.nurse,.is,.collecting,.data,.from,.a,.client,.who,.has,.tuberculosis,.and,.started

4,./,.31