Medsurg EAQ Exam 4 Questions With Complete Solutions
a nurse is admitting a pt. with a thrombotic stroke. the pt. is
NPO but is requesting a drink of water. which response by a
nurse is appropriate? Correct Answers it is not safe to allow
you to have anything by mouth until a swallow assessment can
be performed
A nurse is caring for a patient who had a stroke and is at risk of
venous thromboembolism (VTE). What should be included in
the nursing interventions for such patients? Correct Answers
Note unusual warmth of legs.
Measure the calf and thigh daily.
Observe swelling of lower extremities.
A nurse is caring for a patient who has aphasia after suffering
from a stroke. How will the nurse communicate with the
patient? Correct Answers Make use of gestures.
Present only one thought at a time.
Do not interrupt the patient if he or she is taking too long to
communicate.
A nurse is caring for a patient who is not able to swallow
properly post stroke. What interventions are important to
facilitate patient safety during eating? Correct Answers Place
food on the unaffected side of the mouth.
,Check mouth for pocketing of food.
Help the patient maintain a sitting position for 30 minutes after a
completing meal.
A nurse is delegating responsibilities to unlicensed assistive
personnel for caring for a patient who has suffered from a stroke
this morning. What responsibilities will the nurse assign?
Correct Answers Measure and record urine output
Perform passive and active range-of-motion exercises
A nurse is formulating a discharge teaching plan for a patient
who had a stroke 15 days ago. What instructions should the
nurse include in the plan? Correct Answers Seek spiritual
assistance.
Maintain adequate fluid intake.
Follow-up for rehabilitation therapy is important.
a nurse is measuring the BP of a hypertensive obese pt. who has
been admitted to the hospital for increased blood glucose levels.
while he or she is speaking, the nurse notes that the pt. has
suddenly started mumbling and is unable to articulate words.
which action would the nurse take? Correct Answers treat this
as an emergency and call the health care provider
A nurse is screening patients to determine if administering tissue
plasminogen activator (tPA) for fibrinolytic therapy is an
appropriate intervention. Which patients may be administered
, tPA safely? Select all that apply. Correct Answers A 70-year-
old with blood sugar levels of 110 mg/dLA
40-year-old with history of head injury six months ago
A 25-year-old with history of cholecystectomy two years
previously
A nurse mentor provides teaching to a group of nursing students
about the cardiac manifestations of severe anemia. Which
compensatory cardiac changes would the nurse include? Select
all that apply. Correct Answers tachycardia
heart failure
intermittent claudification
A patient diagnosed with atrial fibrillation has been put on the
oral anticoagulant warfarin. What instructions should the nurse
give the patient? Correct Answers "The drug requires close
monitoring."
"Do not stop the drug without informing the doctor."
A patient has a hemoglobin level of 11 g/dL. The nurse
determines that the patient has which level of severity of
anemia? Correct Answers Mild anemia
In mild anemia, hemoglobin is in the range of 10-12 g/dL. In
severe anemia, it is less than 6 g/dL. Aplastic anemia refers to a
type of anemia caused by a decrease in red blood cell precursors.
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