Medsurg EAQ Exam 4

the nurse provides discharge instructions for a patient who has undergone arthroplasty. which statement by the patient indicates understanding of the instructions?

"I have to do the physical therapy exercises several times a day"

The nurse provides discharge teaching to a patient with sickle cell disease (SCD). Which statements made by the patient indicate understanding of the teaching? Select all that apply.

"I should avoid high altitudes" "I should start screening for retinopathy at age 10."

The registered nurse is teaching a student nurse about airway management for a patient who is at risk of aspiration. Which statement made by the student nurse indicates effective learning?

"I will perform suctioning as needed."

A patient with neutropenia asks how the prescribed protective (reverse) isolation helps prevent the spread of organisms. Which response by the nurse is appropriate?

"It is designed to minimize the spread of germs to you from sources outside your environment."

which laboratory finding for a patient with chronic obstructive pulmonary disease (COPD) is most important to report to the health care provider?

PaCO2 55 mm Hg

A patient with thalassemia major that is receiving a blood transfusion shows signs of hemochromatosis. The nurse anticipates a prescription for what medication?

deferoxamine

which instruction would the nurse include when teaching a patient about the administration of an iron supplement?

dilute the liquid iron and ingest it through a straw

The nurse would place the highest priority on initiating interventions that will reduce which symptom in a patient with a gastrointestinal bleed, a hemoglobin of 8.7%, and a hematocrit of 26%?

dizziness

A patient with peptic ulcer disease has a history of bloody stools, a hemoglobin level of 10 g/dL, and a total iron level of 40 mcg/dL. The nurse would assess for which clinical manifestations? Select all that apply.

pallor chelitis paresthesias

A patient's laboratory report reveals a hemoglobin (Hgb) level of 11 g/dL. The nurse expects to observe which clinical manifestation?

palpitations

physical assessment findings will the nurse expect when caring for a patient with cor pulmonale

pedal edema hepatomegaly JVD

which action by the student nurse while performing chest percussion indicates the need for further teaching?

percussing with both hands simultaneously

which intervention would the nurse delegate to the UAP when working with a patient who had a stroke?

perform passive ROM exercises to flaccid extremities

the nurse assess a patient who has severe anemia and expects to find which manifestations? select all that apply

vertigo dyspnea at rest jaundice and pruritus glossitis and smooth tongue

Which is the purpose of lung reduction surgery for the patient with chronic obstructive pulmonary disease (COPD)?

Allows more room for normal alveoli to expand

Which interventions would the nurse provide a patient who has polycythemia? Select all that apply.

Evaluating fluid intake and output Assessing the patient's nutritional status Initiating active and passive leg exercises

which finding would confirm a diagnosis of COPD in a patient with dyspnea and a hx of tobacco use?

FEV1/FVC ratio of 65%

Which condition results in anemia due to synthesis of defective deoxyribonucleic acid (DNA) in the body?

Folic acid deficiency

Which laboratory report findings support the nurse's conclusion that a patient has thalassemia major? Select all that apply.

Increased bilirubin levels Increased serum iron levels Increased reticulocyte level

The nurse suspects that a patient has polycythemia vera based on which findings in the patient's laboratory reports? Select all that apply.

Increased cobalamin levels Increased hemoglobin levels Increased red blood cell levels Increased white blood cell levels

which interventions would the nurse include in the bladder retaining program of a pt. who had a stroke?

Encourage adequate fluid intake Observe for signs of restlessness Assess bladder distention by palpation

Which are primary methods of preventing a stroke?

Healthy diet Regular exercise Management of blood pressure

which nursing intervention would the nurse include in the plan of care for a pt. with hemorrhagic stroke who is having neuromuscular and cognitive impairment?

encouraging independent exercises

the nurse assesses a pt. experiencing visual disturbances, difficulty swallowing, and decreased LOC with a BP of 280/180 mm Hg. Which action by the nurse is a priority?

ensure patent airway

which intervention would be included in the plan of care for a patient who has experienced a right-brain stroke?

evaluate body positioning during transfers

which factors will the nurse consider when teaching a patient about options for continuous home oxygen (O2) therapy? Select all that apply.

financial resources patients cooperation comfort of the device humidification required fractional inspired oxygen (FiO2) required

which food items would be included in the diet plan for a pt. being discharged from the hospital after recovering from a stroke?

grilled chicken veggie soups

when feeding a pt. with a stroke on the left side, in which position would the nurse place the pt.?

high fowler's position

a pt. underwent aneurysm clipping six hours ago for subarachnoid hemorrhage and is being treated with nimodipine. while examine the pt., the nurse finds that the pulse of the pt. is 50 bpm and the BP is 90/60 mm hg. Which action would the nurse take for this pt.

hold the medication and contact the health care provider

which topics will be included when the nurse is teaching a patient with lung hyperinflation caused by severe chronic obstructive pulmonary disease (COPD)? select all that apply

huff coughing smoking cessation pursed-lip breathing use of airway clearance devices

which explanation is likely when the nurse notes a hemoglobin level of 20 g/dL in a patient admitted with chronic obstructive pulmonary disease?

hypoxia has stimulated erythropoiesis

which factor contributes to loos of lung elastic recoil in a patient with chronic obstructive pulmonary disease (COPD) due to cigarette smoking?

imbalance of protease and antiprotenase activity

which behavior would be exhibited by a pt. who has suffered a right-brain stroke?

impulsive and impatient

which factor causes the clinical manifestations of chronic obstructive pulmonary disease (COPD)?

inability to effectively expire air

a pt. is scheduled for a serial CT scan after a stroke. which rationales would the nurse give the pt. and the pts relatives about this procedure?

it helps to evaluate recovery it helps to assess the effectiveness of treatment

which information would be given to the pt. with a hx of transient ischemic attacks and has been prescribed aspirin?

it is a pain medication and an anti platelet agent it may cause bleeding, which should be reported immediately

which info would be included when explaining to the relatives of a pt. suspected of having a stroke about the importance of undergoing MRI?

it is helpful in identifying the likely causes of stroke it helps to differentiate btwn a stroke and any other brain lesion

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?

it is not safe to allow you to have anything by mouth until a swallow assessment can be performed

Which complication would the nurse expect in a patient with chronic obstructive pulmonary disease who has α1-antitrypsin (AAT) deficiency?

liver disease

when teaching a class on smoking cessation, which benefits of tobacco cessation will the nurse include?

lower cancer risk improvement in chronic cough enhanced sense of taste and smell

Which food would be included in the diet for a patient who had a stroke and has dysphagia?

mashed potatoes

which information about the purpose of pursed-lip breathing will the nurse include when teaching a patient with chronic obstructive pulmonary disease about breathing exercises?

preventing air trapping

which explanation about the effect of pursed-lip breathing will the nurse include when teaching a patient with chronic obstructive pulmonary disease (COPD)?

prevents bronchial collapse and air trapping in the Lunds during expiration

Best characterizes COPD

progressive persistent expiratory airflow limitation

which interventions would the nurse take for a pt. who has been diagnosed with a stroke and is complaining of difficulty in movement of the joints? select all that apply

promote exercises provide hand splints

which nursing interventions would assist the patient who had a right-brain stoke in coping with perceptual deficits?

provide good lighting break tasks into simple steps provide nonslip socks at all times

most common organism found in heated nebulizers used for humidification during oxygen administration

pseudomonas aeruginosa

which action would be beneficial to a patient with a right-brain stroke?

remove clutter and obstacles

while assessing a pt. who sustained a hemorrhagic stroke, the nurse finds that the pt. has decreased gag, cough, and swallowing reflexes. which complication would the nurse expect in the pt.?

risk of aspiration

which nursing intervention would the nurse plan to provide for a patient who had a right-hemispheric stroke?

safety measures

A nurse is caring for a patient who has aphasia after suffering from a stroke. How will the nurse communicate with the patient?

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 had a stroke and is at risk of venous thromboembolism (VTE). What should be included in the nursing interventions for such patients?

Note unusual warmth of legs. Measure the calf and thigh daily. Observe swelling of lower extremities.

A patient with hemorrhagic stroke has undergone aneurysmal occlusion via clipping and has a blood pressure of 90/60 mm Hg. What should be included in postoperative care of the patient?

Start dopamine (Inotropin). Encourage fluid intake. Start crystalloid solution to achieve volume expansion.

which intervention would the nurse take for a patient who has been prescribed nimodipine

administer if HR is greater than 60beats/min

when caring for a patient with chronic obstructive pulmonary disease (COPD) who reports anxiety, which medication prescribed by the health care provider will the nurse question?

alprazolam (the use of benzodiazepines causes reduced respiratory drive and a likely increase in CO2 levels in patients with COPD)

a pt. has left-sided hemiplegia following an ischemic stroke that was experienced 4 days earlier. how would the nurse best promote the health of the pts. integumentary system?

alternate the pts. positioning between supine and side-lying

When caring for a patient diagnosed with cor pulmonale, which finding will the nurse expect?

ankle edema

which nursing interventions would be included in the plan of care to prevent skin breakdown in a pt. who had a stroke? select all that apply

applying emollients to dry skin using pillows under LE

during the acute stage of a stroke, which intervention would be included in the plan of care for a pt. experiencing aphasia?

ask simple yes-and-no questions

which findings will the nurse expect when assessing a clinic patient with chronic obstructive pulmonary disease (COPD)?

barrel chest on inspection wheezes on auscultation

which finding by the nurse indicates possible oxygen toxicity in a patient who has been receiving high oxygen concentrations for several days?

bilateral lung crackles

which benefits of a pulmonary rehabilitation (PR) program will the nurse include when encouraging a patient to consider PR? select all that apply

boosts mood reduces dyspnea enhances quality of life

when a patient with chronic obstructive pulmonary disease (COPD) and stable spirometry testing reports increasing anxiety, the nurse will anticipate an increased dose in which medication?

busprione

which potential side effect would the nurse include when teaching a patient about administration of ferrous gluconate?

constipation

which type of food would the nurse feed the patient by mouth for the first time after a stroke?

crushed ice

which aspects of the medical hx of a female pt. are risk factors for a stroke?

current use of high-dose contraceptives hx of migraine headaches with aura

which topic will the nurse include when teaching a patient with for pulmonale?

low-sodium diet

which patient is most likely to experience anemia related to an increased destruction RBCs

23-year-old African American man who has a diagnosis of sickle cell disease

the nurse is providing discharge instructions to a patient who has anemia secondary to acute blood loss. which instruction would the nurse include in the discharge teaching?

"Now that the blood loss is controlled and as your blood volume is replaced, the anemia corrects itself, so no long-term treatment is needed"

While taking undiluted liquid iron that was prescribed, a patient asks the nurse why it must be drunk through a straw. How should the nurse respond?

"it prevents staining of the teeth"

which instruction would the nurse include when teaching a patient about the administration of an oral iron substitute?

"take it one hour before breakfast, with orange juice"

if a unit of packed RBCs picked up from the lab at 1015, the nurse would plan to hang the unit to begin infusion no later than which time?

1045 the nurse must hang the unit cells within 30 min of signing them out from the blood bank

The nurse understands that with repeated episodes of sickling, which organ is most affected?

lungs

A patient has a hemoglobin level of 11 g/dL. The nurse determines that the patient has which level of severity of anemia?

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. It does not refer to the severity of anemia. In moderate anemia, the hemoglobin it is in the range of 6-10 g/dL. Hemoglobin above 12 g/dL is considered normal (no anemia).

Which erythrocyte characteristic would the nurse expect to see in the laboratory findings for a patient who has experienced acute blood loss?

Normocytic

Which interventions would the nurse expect to be included in the plan of care for a patient with thalassemia major who is anemic and has a history of blood transfusions? Select all that apply.

Zinc supplementation Oral deferasirox (Exjade) Continued blood transfusions Ascorbic acid supplementation

the nurse expects to observe which manifestations in a patient who experience acute blood loss of 2000 mL? Select all that apply

air hunger clammy skin decreased central venous pressure

which assessment finding would the nurse associate with severe anemia?

pallor

The nurse provides dietary teaching to a patient with anemia and would include which food sources to promote red blood cell (RBC) maturation? Select all that apply.

avocados red meat

when a patient is prescribed iron tablets for the treatment of anemia, which measures ensure maximum absorption? Select all that apply

taking the tablet with orange juice taking the tablet an hour before meals

A patient is prescribed oral iron for the treatment of anemia. The nurse should instruct the patient about what side effects? Select all that apply.

heart burn black stools constipation

The nurse reviews a patient's medical record and notes assessment findings which include fatigue, arthralgia, abdominal pain, weight loss, an enlarged liver, and a total body iron level of 70 g. The nurse suspects which condition?

hemochromatosis

the nurse recalls that heparin should not be given to a patient with a hx of condition

heparin-induced thrombocytopenia (HIT)

the nurse reviews documentation of assessment findings of a patient with severe anemia. which assessment finding would the nurse question

hyperpigmentation

The nurse recalls that hemolytic anemia can be caused by which extrinsic factors?

infectious agent

which action would the nurse take to safely infuse one unit of fresh frozen plasma in a patient?

infuse the FFP as rapidly as the patient will tolerate

the nurse is caring for a patient with skeletal traction for an extremity fracture and takes which actions to maintain the traction?

keep the weights off the floor elevate the end of the bed as needed make sure that the traction ranges from 5 to 45 pounds (2.3 to 20.4 kg)

which foods would the nurse encourage the patient to eat in order to provide nutritional support for hemoglobin synthesis? select all that apply

legumes dried fruits dark-green, leafy vegetables

which role does folic acid play in erythropoiesis

promotes RBC maturation

The nurse assesses a patient with pernicious anemia and expects to find which classic sign of this condition?

red, beefy tongue

A patient underwent a total hip arthroplasty (THA). The nurse expects that which interventions will be included in the patients postoperative treatment plan? Select all that apply

regular neuromuscular assessments pain management strategies, which may include epidural or intrathecal analgesia etc exercise of the affected joint use of an abductor pillow prophylactic anticoagulant drug for at least 10-14 days

Which condition is characterized by the presence of a high percentage of hemoglobin S (Hgb S) in the erythrocytes?

sickle cell disease

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.

tachycardia heart failure intermittent claudification

which instructions would the nurse include when teaching a patient about the administration of iron capsules?

take laxatives if needed take the medication with orange juice the medication may cause the stools to become black

Which instruction would the nurse include in the teaching plan for a patient newly diagnosed with microcytic hypochromic anemia?

take the iron with orange juice one hour before meals

the nurse provides education for a group of nursing students and provides which description of carpal tunnel syndrome (CTS)?

the compression of the median nerve that enters the hand through the narrow confines of the carpal tunnel

A patient is admitted to the emergency department with right-sided facial drooping. When taking the patient's history, which information would be most significant?

"When did the facial drooping begin?"

A registered nurse is teaching a student nurse about the management of increased intracranial pressure in a patient who sustained a stroke. Which statement made by the student nurse indicates the need for further teaching?

"The patient should be placed in a supine position."

the nurse is providing education on the drug clopidogrel for a pt. who experienced a TIA. which pt. statement indicates a need for further teaching?

"I need to keep in close contact with my health care provider because I need frequent blood tests to adjust the medication dose."

After the nurse has completed diet and nutrition teaching for a patient with chronic obstructive pulmonary disease (COPD), which patient statements indicate effective learning? Select all that apply.

"I should avoid beans and cabbage.""I can enjoy eating more cold foods and desserts.""I am glad I can have a peanut butter and jelly sandwich at lunch every day."

The registered nurse is teaching a student nurse about acute care for a patient with ischemic stroke. The patient's blood pressure is 230/120 mm Hg. Which statement made by the student nurse indicates the need for further teaching?

"Large amounts of fluid should be provided."

A patient diagnosed with atrial fibrillation has been put on the oral anticoagulant warfarin. What instructions should the nurse give the patient?

"The drug requires close monitoring." "Do not stop the drug without informing the doctor."

which instruction will the nurse include in the diet plan for a patient with chronic obstructive pulmonary disease (COPD)?

"eat ice cream every day"

which statements made by the patient indicate that teaching about safety measures for home oxygen therapy has been successful? select all that apply

"smoking in the house should be avoided" "I should avoid paint thinners in the house" "I can clean the oxygen concentrator with a damp cloth" "Liquid soap should b used to wash the nasal cannula"

A registered nurse is teaching a student nurse about tissue plasminogen activator (tPA) administration in a patient with ischemic stroke. Which statement made by the student nurse indicates a need for further teaching?

"tPA should be administered within 12 hours of the onset of a stroke."

when would the nurse schedule postural drainage for a patient who has COPD

1 hour before a meal

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.

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

Which of these is a clinical manifestation of early chronic obstructive pulmonary disease (COPD)?

A chronic, intermittent cough

A registered nurse is caring for a patient who suffered a stroke one day ago. What is the responsibility of the nurse in caring for this patient?

Assess neurologic status. Assess respiratory status.

A patient has suffered a right-brain stroke. What should the nurse include in the safety measures immediately after the stroke?

Avoid using vests. Elevate the side rails. Use video monitors to observe the patient continuously.

The nurse is discharging a patient admitted with a transient ischemic attack (TIA). For which medications might the nurse expect to provide discharge instructions?

Clopidogrel Enoxaparin Dipyridamole Enteric-coated aspirin

A patient presenting with stroke symptoms is being considered for fibrinolytic therapy. What assessment data would be important to communicate promptly to the prescribing health care provider?

Colonoscopy for evaluation of blood in the stools one week ago

Immediately after a stroke, the nurse takes the blood pressure (BP) of the patient and finds it to be 80/60 mm Hg. What should be the plan of action of the nurse for this finding?

Correct hypotension. Correct hypovolemia. Continue treatment for stroke.

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?

Measure and record urine output Perform passive and active range-of-motion exercises

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?

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.

The nurse is planning psychosocial support for the patient and family of the patient who suffered a stroke. What factor most likely will have the greatest impact on positive family coping with the situation?

Rehabilitation potential of the patient

Which physiologic effect of ongoing tobacco smoking leads to chronic obstructive pulmonary disease (COPD)?

Respiratory tract cell hyperplasia

when caring for a patient admitted with a new diagnosis of chronic obstructive pulmonary disease (COPD), which medication prescribed by the health care provider will the nurse question?

Roflumilast

which finding indicates that a patient with COPD requires home oxygen therapy

SaO2 87% at rest (patient with an oxygen saturation less than 88% when resting requires oxygen therapy)

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?

Seek spiritual assistance. Maintain adequate fluid intake. Follow-up for rehabilitation therapy is important.

which action will the nurse include in the plan of care for a patient with an exacerbation of chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 1 L/min by nasal cannula?

adjust oxygen flow rate to keep oxygen saturation at 90%

which nursing intervention would be included in the plan of care for a patient who is admitted with a stroke and is complaining about having liquid stools?

checking for stool impaction

which prescription would the nurse question for a patient who is admitted with a hemorrhagic stroke

clopidogrel 75 mg PO once daily

which action can the nurse delegate to the UAP to reduce fatigue for a pt. recovering from a stroke at mealtimes?

cut up the meat for the pt.

a pt. who experienced a stroke on the left side of the brain suddenly begins to cry while playing a card game. which action would the nurse take?

distract the pt

when caring for a patient with COPD who has increased BNP levels, which treatment will the nurse anticipate administering?

diuretics

when the nurse needs to transport a patient who needs an FiO2 of 45% to a different department, which oxygen delivery device will be best to use?

simple face mask

which instruction will the nurse give a patient with chronic obstructive pulmonary disease who is using the flutter airway clearance device?

sit upright while using the device

which information would the nurse give a pt. who had a TIA and is being discharged home?

smoking cessation decreases risk of a stroke HTN is the most important modifiable stroke risk factor diabetes increases the risk of stroke

which diagnostic test for a patient with a chronic cough will be most useful in making a diagnosis of COPD

spirometry

which instruction will the nurse include when teaching a patient with chronic obstructive pulmonary disease (COPD) about use of theophylline?

take the medication with food

which expected outcome would be included in the plan of care for a patient who had a stroke and is experiencing residual expressive aphasia?

the patient will demonstrate alternative communication techniques

which rationale is accurate for why the use of video games would be included in the plan of care for a pt. who sustained a stroke?

the patient's motor skills can be improved

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?

treat this as an emergency and call the health care provider

which postural drainage position will the nurse avoid when caring for a patient with chronic obstructive pulmonary disease and cor pulmonale?

trendelenburg position

which intervention would the nurse take when communicating with a pt. suffering from aphasia following a stroke?

use simple, short sentences accompanied by visual cues to enhance comprehension

which interventions would be included in the plan of care to prevent skin breakdown in a pt. with paralysis due to a stroke?

using emollients on the skin providing good skin care and hygiene using a special mattress for pressure relief

which action would help a nurse to communicate better with a stroke pt. with aphasia?

utilizing touch

The nurse is performing chest physiotherapy on a patient with chronic obstructive pulmonary disease. What appropriate techniques should be used when performing the procedure on this patient? Select all that apply.

vibration percussion postural drainage

which complications would the nurse monitor for when caring for a patient with COPD and for pulmonate? select all that apply

weight gain polycythemia hepatomegaly JVD

when a patient with chronic obstructive pulmonary disease has been using a beclomethasone inhaler, which assessment finding indicates a need for patient teaching?

white patches on pharynx

when a patient hospitalized with chronic obstructive pulmonary disease (COPD) asks the nurse whether oxygen use will be needed at home, which response by the nurse is best?

you will qualify for supplemental oxygen therapy if your resting oxygen saturation drops to 88%