MEDSURG VATI ASSESSMENT FINAL EXAM ACTUAL
QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is reinforcing teaching about foods high in calcium with a client who has
hypocalcemia.
Which of the following foods should the nurse recommend as containing the most
calcium
- 3oz canned salmon
-one small baked potato
- 1 cup diced chicken breast
- one medium banana - ✔✔3oz canned salmon
The nurse should determine that 3 oz canned salmon is the best food source to
recommend because it contains 187.2 mg of calcium per serving. Other food sources
high in calcium include sardines, tofu, milk, and milk products. The nurse should also
instruct the client to spend time in the sunlight each day to absorb vitamin D and
engage in weight-bearing exercise to help metabolize calcium.
✔✔A nurse is reinforcing teaching with the caregiver of a client who has a visual
impairment due to
macular degeneration. Which of the following comments by the client's caregiver
indicates an
understanding of the teaching
- I will close the blinds to manage glare - ✔✔I will close the blinds to manage glare
Glare from direct sunlight or light that is intensified through glass, such as windows, can
further impair the client's vision and place them at risk for injury. The client's caregiver
can use blinds or shades to minimize glare, and the client can wear yellow- or amber-
tinted glasses to minimize glare.
✔✔A nurse is preparing to perform a closed irrigation of an indwelling urinary catheter
for a client who had abdominal surgery. Which of the following actions should the nurse
plan to take
- stop the irrigation if resistant felt during fluid instillation
- Place the client in semi Fowler position with knees bent
-Cool the irrigation solution prior to instillation into the catheter
-Inject the solution by pushing the plunger using short rapid movement - ✔✔- stop the
irrigation if resistant felt during fluid instillation
The nurse should plan to discontinue the irrigation and contact the provider if resistance
is felt. This can indicate the client has a total occlusion of the catheter or that the
catheter is displaced.
✔✔A nurse in a long term facility is delegating client care tasks to staff members. Which
of the following tasks should the nurse assign to an assistive personnel (AP)?
, - Document a client's output for the shift - ✔✔- Document a client's output for the shift
✔✔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
manifestations as an adverse effect of
the medication.
- Tinnitus - ✔✔- Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing loss.
Audiometry is recommended for clients receiving prolonged IV furosemide.
✔✔A nurse is collecting data from a client who has acute cholecystitis. Which of the
following manifestations should the nurse expect
- Pain radiating to the right shoulder - ✔✔- Pain radiating to the right shoulder
Pain radiating to the right shoulder is a common manifestation of acute cholecystitis due
to the contraction of the bile ducts of the gallbladder.
✔✔A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the
following findings should the nurse expect?
- Fruity breath odor - ✔✔- Fruity breath odor
The nurse should expect a client who has DKA to exhibit an acetone or fruity breath
odor. This occurs as the lungs attempt to rid the body of excess ketones.
✔✔A nurse is caring for a client who is preoperative and does not speak the same
language as the nurse. Which of the following actions should the nurse take
- Incorporate the use of the pictures as a tool of communication - ✔✔- Incorporate the
use of the pictures as a tool of communication
The nurse should use communication tools, such as a message board, cards, or
pictures, to assist the client in communicating her needs.
✔✔A nurse is caring for a client who is scheduled for a right total hip arthroplasty.
Which of the following actions should the nurse take prior to the procedure? SATA
- Collect data from the client about any allergies
- Ask the client to state her first and last name
- Verify the client has signed the consent form is correct - ✔✔- Collect data from the
client about any allergies
- Ask the client to state her first and last name
- Verify the client has signed the consent form is correct
✔✔A nurse is reinforcing teaching with a client who has hypertension and a prescription
for Lisinopril.
Which of the following information should the nurse include in the teaching
QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is reinforcing teaching about foods high in calcium with a client who has
hypocalcemia.
Which of the following foods should the nurse recommend as containing the most
calcium
- 3oz canned salmon
-one small baked potato
- 1 cup diced chicken breast
- one medium banana - ✔✔3oz canned salmon
The nurse should determine that 3 oz canned salmon is the best food source to
recommend because it contains 187.2 mg of calcium per serving. Other food sources
high in calcium include sardines, tofu, milk, and milk products. The nurse should also
instruct the client to spend time in the sunlight each day to absorb vitamin D and
engage in weight-bearing exercise to help metabolize calcium.
✔✔A nurse is reinforcing teaching with the caregiver of a client who has a visual
impairment due to
macular degeneration. Which of the following comments by the client's caregiver
indicates an
understanding of the teaching
- I will close the blinds to manage glare - ✔✔I will close the blinds to manage glare
Glare from direct sunlight or light that is intensified through glass, such as windows, can
further impair the client's vision and place them at risk for injury. The client's caregiver
can use blinds or shades to minimize glare, and the client can wear yellow- or amber-
tinted glasses to minimize glare.
✔✔A nurse is preparing to perform a closed irrigation of an indwelling urinary catheter
for a client who had abdominal surgery. Which of the following actions should the nurse
plan to take
- stop the irrigation if resistant felt during fluid instillation
- Place the client in semi Fowler position with knees bent
-Cool the irrigation solution prior to instillation into the catheter
-Inject the solution by pushing the plunger using short rapid movement - ✔✔- stop the
irrigation if resistant felt during fluid instillation
The nurse should plan to discontinue the irrigation and contact the provider if resistance
is felt. This can indicate the client has a total occlusion of the catheter or that the
catheter is displaced.
✔✔A nurse in a long term facility is delegating client care tasks to staff members. Which
of the following tasks should the nurse assign to an assistive personnel (AP)?
, - Document a client's output for the shift - ✔✔- Document a client's output for the shift
✔✔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
manifestations as an adverse effect of
the medication.
- Tinnitus - ✔✔- Tinnitus
The nurse should monitor clients who take furosemide for tinnitus and hearing loss.
Audiometry is recommended for clients receiving prolonged IV furosemide.
✔✔A nurse is collecting data from a client who has acute cholecystitis. Which of the
following manifestations should the nurse expect
- Pain radiating to the right shoulder - ✔✔- Pain radiating to the right shoulder
Pain radiating to the right shoulder is a common manifestation of acute cholecystitis due
to the contraction of the bile ducts of the gallbladder.
✔✔A nurse is collecting data from a client who has diabetic ketoacidosis. Which of the
following findings should the nurse expect?
- Fruity breath odor - ✔✔- Fruity breath odor
The nurse should expect a client who has DKA to exhibit an acetone or fruity breath
odor. This occurs as the lungs attempt to rid the body of excess ketones.
✔✔A nurse is caring for a client who is preoperative and does not speak the same
language as the nurse. Which of the following actions should the nurse take
- Incorporate the use of the pictures as a tool of communication - ✔✔- Incorporate the
use of the pictures as a tool of communication
The nurse should use communication tools, such as a message board, cards, or
pictures, to assist the client in communicating her needs.
✔✔A nurse is caring for a client who is scheduled for a right total hip arthroplasty.
Which of the following actions should the nurse take prior to the procedure? SATA
- Collect data from the client about any allergies
- Ask the client to state her first and last name
- Verify the client has signed the consent form is correct - ✔✔- Collect data from the
client about any allergies
- Ask the client to state her first and last name
- Verify the client has signed the consent form is correct
✔✔A nurse is reinforcing teaching with a client who has hypertension and a prescription
for Lisinopril.
Which of the following information should the nurse include in the teaching
