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MEDSURG VATI ASSESSMENT 90 Q'S questions and answers graded A+ 2024/2025
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MEDSURG VATI ASSESSMENT 90 Q'S questions and answers graded A+ 2024/2025
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MEDSURG VATI ASSESSMENT 90 Q'SA nurse is helping with the care of 4 clients. Which of the subsequent clients is the priority for
the nurse to look
-A customer who has chest tubes and an oxygen Sat of 90%
- aclient who has peripheral edema and urinary output of a hundred thirty over 4hrs
- A patron who has a everlasting pacemaker with heart price of 76/min
-a client who has pericarditis and temp. 38 c one hundred.4 - ANS- A purchaser who has chest
tubes and an oxygen Sat of ninety%
Using the airway, breathing, and circulate technique to customer care, the nurse need to
determine that the priority locating is the client's oxygen saturation level, that is beneath the
predicted reference variety of 95% to one hundred%. Therefore, the nurse ought to attend to
this purchaser first.
A nurse is accumulating records from a customer who changed into admitted with a Glasgow
Coma Scale of 3. Which
of the following findings need to the nurse expect?
- Vacalizes sound
-Blinks eyes whilst asked
-Follows motor commands
-Nonresponsive Commands - ANSNonresponsive Commands
A purchaser who has a GCS of less than 8 has proof of intense head harm and is in a comatose
country. The GCS is a standardized device that allows for the assessment of a client's stage of
cognizance. The take a look at is divided into three sections that examine eye opening, motor
reaction, and verbal reaction. The GCS degrees from a excessive rating of 15 (fully alert) to a
low score of 3 (completely comatose).
A nurse is monitoring a patron who has a pneumothorax and a chest tube in area with a closed
chest drainage machine connected to low suction. For which of the following findings should the
nurse notify the charge nurse
- Fluctation of the water level within the water seal chamber
-consistent bubling inside the suction manage chamber
- periodic bubbling in the water seal chamber
- Persistent effervescent within the water seal chamber - ANS- Persistent bubbling in the water
seal chamber
Excessive and persistent bubbling inside the water-seal chamber shows an air leak in the
drainage gadget. The nurse have to notify the charge nurse of this finding.
,A nurse is reinforcing coaching with a male purchaser who has right sided hemiparesis about
preforming ADL's. Which of the following instructions must the nurse include inside the teaching
-Comb your hair with the unaffected arm
-Dress your unaffected facet first
choose apparel with buttons
-shave together with your affected facet - ANSComb your hair with the unaffected arm
The nurse have to instruct the patron to comb their hair with the unaffected arm to lessen
frustration and growth independence and shallowness.
A nurse is gathering records from a customer and auscultates intermittent excessive-pitched
sounds at some point of concept over the decrease base of the lungs. The nurse must perceive
this locating as which of the subsequent lungs sounds
- Fine crackles
-stridor
-rhonchi
-friction - ANS- Fine crackles
Fine crackles are auscultated in the base of the lungs as air movements thru airway secretions.
Fine crackles are intermittent, excessive-pitched sounds heard greater regularly in the course of
concept.
A nurse is collecting information from a consumer who has coronary artery disorder. Which of
the subsequent
manifestations ought to the nurse pick out as a demonstration that the purchaser has angina (
SatA)
- Chest Discomfort Radiated
- Pain lasting less that 15mins
- Pain that is relieved with relaxation - ANS- Chest Discomfort Radiated
- Pain lasting much less that 15mins
- Pain that is relieved with res
A nurse is receiving exchange-of-shift document for a group of clients. Which of the following
clients
must the nurse plan to look first?
- A client who has diabetes mellitus with diaphoretic - ANSA customer who has diabetes mellitus
with diaphoretic
When the usage of the urgent vs. Nonurgent technique to purchaser care, the nurse need to
determine that the priority movement is to attend to a patron who has diabetes mellitus and is
diaphoretic. Diaphoresis is a manifestation of hypoglycemia and may result in decreased
, cerebral characteristic. The nurse have to test the patron's blood glucose and administer a
fast-performing glucose as prescribed.
A nurse is collecting data from a consumer who has tuberculosis and commenced combination
remedy
2months in the past. Which of the following diagnostic outcomes shows that the consumer is
adhering to the
medicine routine.
- A bad chest X-ray
- A poor sputum tradition
-A bad tuberculin skin check
-A terrible titer for cytomegalovirus - ANSA poor sputum culture
Tuberculosis is an infectious sickness spread thru airborne droplets. Sputum cultures are
received to both diagnose tuberculosis and to decide whether or not the medicine treatment has
been effective. After the patron starts offevolved antibiotic treatment for tuberculosis, a sputum
subculture is received month-to-month. A terrible subculture is an indication that the purchaser
is now not infectious and the medicine therapy has been powerful.
A nurse is gathering facts from a consumer who has bacterial meningitis. Which of the
subsequent
findings need to the nurse anticipate?
- Severe Headache - ANS- Severe Headache
The nurse must count on a purchaser who has meningitis to have severe and continual
headaches that get worse with movement of the head.
A nurse is reinforcing with a customer who has pernicious anemia. Which of the following
statements via the client indicated an information of the teaching
- I will be able to switch to a nasal form of cyanocobalamin while my degrees stabilize - ANSI
might be able to transfer to a nasal shape of cyanocobalamin whilst my tiers stabilize
A nurse is reinforcing discharge teaching with a patron who has COPD and reports episodes of
dyspnea. Which of the following commands must the nurse consist of?
- Used the pursed lip breathing method - ANSUsed the pursed lip respiratory technique
A purchaser who has COPD need to use the pursed-lip respiratory approach to prolong
exhalation, which increases nice stress within the lungs, decreases dyspnea, and promotes air
exchange.
A nurse is reinforcing coaching with a consumer who has varicose veins of the proper lower
extremity.
Which of the subsequent commands need to the nurse include within the teaching
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