MEDSURG VATI ASSESSMENT COMPREHENSIVE EXAM
ACTUAL QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is collecting data from a client who has a fracture of the femur. The nurse
notes respiratory distress, fever, and petechiae. Which of the following actions should
the nurse take after notifying the provider
- Place the clients in high fowlers position
- administer low flow oxygen via nasal cannula
-sponce the client with cold water
-prepare the client for fasciotomy - ✔✔- Place the clients in high fowlers position
The nurse should identify that the client is experiencing manifestations of a fat
embolism, a life-threatening complication of long bone fractures. This occurs when fat
globules lodge in small vessels, leading to vessel rupture and the release of fat globules
into the circulation. The nurse should place the client in high-Fowler's position to
facilitate lung expansion and oxygenation.
✔✔A nurse is reinforcing teaching with a 73 year old female client above preventing
osteoporosis.
Which of the following information should the nurse include
- Take 2000 international units of Vit D - ✔✔Take 2000 international units of Vit D
✔✔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 - ✔✔- 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 dysrhythmias due to digoxin toxicity.
Potassium assists in displacing digoxin, because digoxin binds to potassium, and
reduces the risk for digoxin toxicity.
✔✔A nurse is collecting data from a client who has left homonymous hemianopia
following a stroke. Which of the following cclient findings effective management of
homonymous hemianopsia
- drink nectar thick liquid without coughing
- Increases communication
-display less weakness in the right arm
- Eats item from both sides of the lunch tray - ✔✔- Eats item from both sides of the
lunch tray
Left homonymous hemianopsia is blindness in the left visual field of both eyes. A client
who eats from both sides of their lunch tray is turning their head from side to side,
displaying effective management of left homonymous hemianopsia.
, ✔✔A nurse is reinforcing discharge teaching with a client who has a new cast. The
client is prescribed hydrocodone for pain. The nurse should instruct the client to report
immediately which
of the following findings to the provider
- Swelling of the affected extremity - ✔✔- Swelling of the affected extremity
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding for the client to report to the provider is swelling of the
affected extremity. This should be immediately reported to the provider because it is an
indication of external pressure restricting blood flow and can result in the development
of compartment syndrome and loss of function.
✔✔A nurse is contributing to the plan of care for a child who had a stroke and is
experiencing dysphagia. Which of the following interventions should the nurse include in
the plan
- Keep the clients glasses of liquid at least two thirds full - ✔✔- Keep the clients glasses
of liquid at least two thirds full
The nurse should keep the client's glasses of liquid at least two-thirds full so the client
can drink the liquids without tilting their head back, which can increase the risk for
aspiration.
✔✔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 urticarial. After stopping the IV infusion, which of the following actions should the
nurse take first?
-Check clients respiration - ✔✔Check clients respiration
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 nurse is collecting data for a client who has new ileostomy. which of the following
finding about the stoma should the nurse report to the provider
- Purple in appearance - ✔✔- Purple in appearance
A stoma that appears purple in appearance can indicate inadequate blood flow to the
stoma. The nurse should report the finding immediately to the provider.
✔✔A nurse is caring for a client who has Phantom pain after healing from a below knee
amputation. which of the followingmedication should the nurse expect the provider to
prescribe to relieve the clients pain?
- Pregablin - ✔✔Pregabalin
ACTUAL QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is collecting data from a client who has a fracture of the femur. The nurse
notes respiratory distress, fever, and petechiae. Which of the following actions should
the nurse take after notifying the provider
- Place the clients in high fowlers position
- administer low flow oxygen via nasal cannula
-sponce the client with cold water
-prepare the client for fasciotomy - ✔✔- Place the clients in high fowlers position
The nurse should identify that the client is experiencing manifestations of a fat
embolism, a life-threatening complication of long bone fractures. This occurs when fat
globules lodge in small vessels, leading to vessel rupture and the release of fat globules
into the circulation. The nurse should place the client in high-Fowler's position to
facilitate lung expansion and oxygenation.
✔✔A nurse is reinforcing teaching with a 73 year old female client above preventing
osteoporosis.
Which of the following information should the nurse include
- Take 2000 international units of Vit D - ✔✔Take 2000 international units of Vit D
✔✔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 - ✔✔- 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 dysrhythmias due to digoxin toxicity.
Potassium assists in displacing digoxin, because digoxin binds to potassium, and
reduces the risk for digoxin toxicity.
✔✔A nurse is collecting data from a client who has left homonymous hemianopia
following a stroke. Which of the following cclient findings effective management of
homonymous hemianopsia
- drink nectar thick liquid without coughing
- Increases communication
-display less weakness in the right arm
- Eats item from both sides of the lunch tray - ✔✔- Eats item from both sides of the
lunch tray
Left homonymous hemianopsia is blindness in the left visual field of both eyes. A client
who eats from both sides of their lunch tray is turning their head from side to side,
displaying effective management of left homonymous hemianopsia.
, ✔✔A nurse is reinforcing discharge teaching with a client who has a new cast. The
client is prescribed hydrocodone for pain. The nurse should instruct the client to report
immediately which
of the following findings to the provider
- Swelling of the affected extremity - ✔✔- Swelling of the affected extremity
When using the urgent vs. nonurgent approach to client care, the nurse should
determine that the priority finding for the client to report to the provider is swelling of the
affected extremity. This should be immediately reported to the provider because it is an
indication of external pressure restricting blood flow and can result in the development
of compartment syndrome and loss of function.
✔✔A nurse is contributing to the plan of care for a child who had a stroke and is
experiencing dysphagia. Which of the following interventions should the nurse include in
the plan
- Keep the clients glasses of liquid at least two thirds full - ✔✔- Keep the clients glasses
of liquid at least two thirds full
The nurse should keep the client's glasses of liquid at least two-thirds full so the client
can drink the liquids without tilting their head back, which can increase the risk for
aspiration.
✔✔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 urticarial. After stopping the IV infusion, which of the following actions should the
nurse take first?
-Check clients respiration - ✔✔Check clients respiration
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 nurse is collecting data for a client who has new ileostomy. which of the following
finding about the stoma should the nurse report to the provider
- Purple in appearance - ✔✔- Purple in appearance
A stoma that appears purple in appearance can indicate inadequate blood flow to the
stoma. The nurse should report the finding immediately to the provider.
✔✔A nurse is caring for a client who has Phantom pain after healing from a below knee
amputation. which of the followingmedication should the nurse expect the provider to
prescribe to relieve the clients pain?
- Pregablin - ✔✔Pregabalin
