MEDSURG VATI ASSESSMENT UPDATED EXAM SCRIPT
QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is reviewing the medical record of a client who has systemic lupus
erythematosus. Which of the following findings should the nurse expect
- Joint pain - ✔✔- Joint pain
The nurse should expect a client who has SLE to exhibit manifestations such as joint
pain, photosensitivity, hair loss, and malaise. SLE is an autoimmune disease that
causes the body to produce antibodies that attack body cells instead of pathogens, such
as bacteria and fungi.
✔✔A nurse is reinforcing dietary teaching with a client who has a new diagnosis of
GERD about
foods to avoid because they worsen the manifestations of GERD. Which of the following
foods should the nurse instruct the clients to avoid
- Peppermint - ✔✔- Peppermint
The nurse should remind the client that foods that relax the esophageal sphincter and
thus worsen the manifestations of GERD include peppermint and spearmint. GERD is a
condition in which gastric acids and gastric contents reflux into the esophagus due to
delayed stomach emptying or relaxation of the lower esophageal sphincter.
✔✔A nurse is planning care for a client who is receiving bolus enteral feedings and is
prescribed digoxin and furosemide. Which of the following actions should the nurse take
- Flush the tube with water before and after each medication - ✔✔Flush the tube with
water before and after each medication
The nurse should flush the tube with at least 15 mL of water before and after each
medication to ensure the client receives the total dose of the medication and to reduce
the risk of clogging the tube.
✔✔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 back up system
- check oxygen system weekly
-Instruct family memebr to smoke in the another room
-store oxygen tank horizontal - ✔✔- Maintain an electrical back up system
The nurse should remind the client to maintain an electrical backup system to ensure
continuity of oxygen therapy. This includes notifying local emergency medical services
,and the electric company of the use of home oxygen equipment. In the event of power
loss, the client should notify 911, the provider, and the home health care agency.
✔✔21) A nurse is caring for a client who has type 1 diabetes mellitus and reports
hunger and weakness. The clients blood glucose is 50gm/dL. Which of the following
actions should the nurse take
-Have the client drink a glass of milk - ✔✔-Have the client drink a glass of milk
✔✔A nurse is assisting a client who has hypertension in making healthy dietary
selections regarding
sodium intake. Which of the following foods should the nurse instruct the client to avoid?
- Pretzels - ✔✔- Pretzels
✔✔A nurse is collecting data from a client who has a new diagnosis of
pheochromocytoma. Which
of the following findings should the nurse expect
- Hypertension - ✔✔Hypertension
The nurse should expect a client who has a pheochromocytoma to exhibit severe
hypertension. The client's systolic blood pressure can be as high as 300 mm Hg, with a
diastolic blood pressure exceeding 150 mm Hg. Other manifestations include nausea,
diaphoresis, weakness, and severe headache. Pheochromocytoma is a rare tumor of
the adrenal gland that secretes excessive amounts of epinephrine and norepinephrine.
✔✔A nurse is reinforcing teaching with a client who has gastric bleeding and is to have
a gastric
lavage by closed system irrigation. Which of the following statements should the nurse
include?
- You should expect to be positioned in a semi-upright position - ✔✔You should expect
to be positioned in a semi-upright position
The nurse should place the client in a semi-Fowler's or high-Fowler's position to
enhance the flow of the irrigating solution during the gastric lavage. Gastric lavage
removes large amounts of blood, including clots, and other gastric contents, and
irrigates the lining of the stomach.
✔✔A nurse is collecting data from a client who has right-sided heart failure. Which of
the following
findings should the nurse expect SATA
- Peripheral Edema
- Hepatomegaly
- Abdominal Distension - ✔✔- Peripheral Edema
Right-sided heart failure causes edema in the feet, ankles, legs, and sacrum.
- Hepatomegaly
, Hepatomegaly is a manifestation of right-sided heart failure.
- Abdominal Distension
Right-sided heart failure causes abdominal distention and ascites. It also causes weight
gain, dyspnea, and jugular vein distention.
✔✔A nurse is reinforcing teaching with a client who is experiencing neutropenia as a
result of
chemotherapy. Which of the following information should the nurse include
- examine the feet weekly
- Bathe with antimicrobial soap daily
- Take temperature daily
- Avoid gardening
-include fresh fruit in the diet - ✔✔- Bathe with antimicrobial soap daily
The nurse should instruct the client to bathe daily with antimicrobial soap and to wash
his hands frequently with either an antimicrobial soap or an alcohol-based hand rub to
decrease the risk for infection.
- Take temperature daily
The nurse should instruct the client to check his temperature daily because an increase
in temperature can indicate infection.
- Avoid gardening
Coming into contact with bacteria in the soil while gardening increases the client's risk
for infection.
✔✔A nurse is reinforcing teaching about home care with the caregiver of a client who is
in the early
stages of Alzheimer's disease. Which of the following information should the nurse
include
- Put labels on the kitchen cabinets and drawers - ✔✔Put labels on the kitchen cabinets
and drawers
The nurse should instruct the caregiver to put labels or symbols on common areas,
such as the door of the bathroom, kitchen cabinets, and drawers. A client who is in the
early stages of Alzheimer's disease can have difficulty finding common items or
recalling their location. Labeling prevents the client from having to look in numerous
places to locate an item.
✔✔A nurse is collecting data from a nurse who has sodium level of 128mEq/L. Which of
the following
findings should the nurse expect
- Mental Confusion - ✔✔- Mental Confusion
QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is reviewing the medical record of a client who has systemic lupus
erythematosus. Which of the following findings should the nurse expect
- Joint pain - ✔✔- Joint pain
The nurse should expect a client who has SLE to exhibit manifestations such as joint
pain, photosensitivity, hair loss, and malaise. SLE is an autoimmune disease that
causes the body to produce antibodies that attack body cells instead of pathogens, such
as bacteria and fungi.
✔✔A nurse is reinforcing dietary teaching with a client who has a new diagnosis of
GERD about
foods to avoid because they worsen the manifestations of GERD. Which of the following
foods should the nurse instruct the clients to avoid
- Peppermint - ✔✔- Peppermint
The nurse should remind the client that foods that relax the esophageal sphincter and
thus worsen the manifestations of GERD include peppermint and spearmint. GERD is a
condition in which gastric acids and gastric contents reflux into the esophagus due to
delayed stomach emptying or relaxation of the lower esophageal sphincter.
✔✔A nurse is planning care for a client who is receiving bolus enteral feedings and is
prescribed digoxin and furosemide. Which of the following actions should the nurse take
- Flush the tube with water before and after each medication - ✔✔Flush the tube with
water before and after each medication
The nurse should flush the tube with at least 15 mL of water before and after each
medication to ensure the client receives the total dose of the medication and to reduce
the risk of clogging the tube.
✔✔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 back up system
- check oxygen system weekly
-Instruct family memebr to smoke in the another room
-store oxygen tank horizontal - ✔✔- Maintain an electrical back up system
The nurse should remind the client to maintain an electrical backup system to ensure
continuity of oxygen therapy. This includes notifying local emergency medical services
,and the electric company of the use of home oxygen equipment. In the event of power
loss, the client should notify 911, the provider, and the home health care agency.
✔✔21) A nurse is caring for a client who has type 1 diabetes mellitus and reports
hunger and weakness. The clients blood glucose is 50gm/dL. Which of the following
actions should the nurse take
-Have the client drink a glass of milk - ✔✔-Have the client drink a glass of milk
✔✔A nurse is assisting a client who has hypertension in making healthy dietary
selections regarding
sodium intake. Which of the following foods should the nurse instruct the client to avoid?
- Pretzels - ✔✔- Pretzels
✔✔A nurse is collecting data from a client who has a new diagnosis of
pheochromocytoma. Which
of the following findings should the nurse expect
- Hypertension - ✔✔Hypertension
The nurse should expect a client who has a pheochromocytoma to exhibit severe
hypertension. The client's systolic blood pressure can be as high as 300 mm Hg, with a
diastolic blood pressure exceeding 150 mm Hg. Other manifestations include nausea,
diaphoresis, weakness, and severe headache. Pheochromocytoma is a rare tumor of
the adrenal gland that secretes excessive amounts of epinephrine and norepinephrine.
✔✔A nurse is reinforcing teaching with a client who has gastric bleeding and is to have
a gastric
lavage by closed system irrigation. Which of the following statements should the nurse
include?
- You should expect to be positioned in a semi-upright position - ✔✔You should expect
to be positioned in a semi-upright position
The nurse should place the client in a semi-Fowler's or high-Fowler's position to
enhance the flow of the irrigating solution during the gastric lavage. Gastric lavage
removes large amounts of blood, including clots, and other gastric contents, and
irrigates the lining of the stomach.
✔✔A nurse is collecting data from a client who has right-sided heart failure. Which of
the following
findings should the nurse expect SATA
- Peripheral Edema
- Hepatomegaly
- Abdominal Distension - ✔✔- Peripheral Edema
Right-sided heart failure causes edema in the feet, ankles, legs, and sacrum.
- Hepatomegaly
, Hepatomegaly is a manifestation of right-sided heart failure.
- Abdominal Distension
Right-sided heart failure causes abdominal distention and ascites. It also causes weight
gain, dyspnea, and jugular vein distention.
✔✔A nurse is reinforcing teaching with a client who is experiencing neutropenia as a
result of
chemotherapy. Which of the following information should the nurse include
- examine the feet weekly
- Bathe with antimicrobial soap daily
- Take temperature daily
- Avoid gardening
-include fresh fruit in the diet - ✔✔- Bathe with antimicrobial soap daily
The nurse should instruct the client to bathe daily with antimicrobial soap and to wash
his hands frequently with either an antimicrobial soap or an alcohol-based hand rub to
decrease the risk for infection.
- Take temperature daily
The nurse should instruct the client to check his temperature daily because an increase
in temperature can indicate infection.
- Avoid gardening
Coming into contact with bacteria in the soil while gardening increases the client's risk
for infection.
✔✔A nurse is reinforcing teaching about home care with the caregiver of a client who is
in the early
stages of Alzheimer's disease. Which of the following information should the nurse
include
- Put labels on the kitchen cabinets and drawers - ✔✔Put labels on the kitchen cabinets
and drawers
The nurse should instruct the caregiver to put labels or symbols on common areas,
such as the door of the bathroom, kitchen cabinets, and drawers. A client who is in the
early stages of Alzheimer's disease can have difficulty finding common items or
recalling their location. Labeling prevents the client from having to look in numerous
places to locate an item.
✔✔A nurse is collecting data from a nurse who has sodium level of 128mEq/L. Which of
the following
findings should the nurse expect
- Mental Confusion - ✔✔- Mental Confusion
