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VATI Med-Surg pre-assessment Practice Questions and Answers

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VATI Med-Surg pre-assessment Practice Questions and Answers A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply.) A. Dyspnea B. G...

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  • November 11, 2024
  • 26
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
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VATI Med-Surg pre-assessment Practice

Questions and Answers


A nurse is preparing to administer a transfusion of RBCs to a client who has heart failure. For which of

the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that

apply.)




A. Dyspnea


B. Gastrointestinal bloating


C. Jugular vein distention


D. Confusion


E. Hypotension - ANSWER✔✔-A. Dyspnea


C. Jugular vein distention


D. Confusion




Dyspnea is a clinical manifestation of fluid volume overload. Jugular vein distention is a clinical

manifestation of fluid volume overload. Confusion is a clinical manifestation of fluid volume overload.


A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic

dysreflexia. Which of the following actions should the nurse take first?

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A. Check the client for a fecal impaction.


B. Examine the client for areas of skin breakdown.


C. Check the client's bladder for distention.


D. Place the client in a sitting position. - ANSWER✔✔-D. Place the client in a sitting position.




The nurse should use the least invasive intervention first. Therefore, the nurse should place the client in

a sitting position to decrease the manifestation of hypertension.




The nurse might have to check the client for fecal impaction, which can precipitate autonomic

dysreflexia. However, the nurse should use a less invasive intervention first. The nurse might have to

examine the client's skin for areas of skin breakdown or pressure, which can trigger autonomic

dysreflexia. However, the nurse should use a less invasive intervention first. The nurse might have to

check the client for bladder distention, which can precipitate autonomic dysreflexia. However, the nurse

should use a less invasive intervention first.


A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have

surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that

apply.)




A. Poor nutritional state




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B. Altered mental status


C. Obesity


D. Pain medication administration


E. Wound infection - ANSWER✔✔-A. Poor nutritional state


C. Obesity


E. Wound infection


A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation.

Which of the following interventions should the nurse take to reduce the risk for ventilator-associated

pneumonia?




A. Position the head of the client's bed in the flat position.


B. Turn the client every 4 hr.


C. Rinse the client's mouth with an antimicrobial solution every 4 hr.


D. Perform hand hygiene prior to suctioning the client's endotracheal tube. - ANSWER✔✔-C. Rinse the

client's mouth with an antimicrobial solution every 4 hr.




The nurse should brush the client's teeth every 8 hr and rinse the client's mouth with an antimicrobial

rinse every 2 hr to reduce the growth of bacteria.




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