Med-Surg EXAM 222 A GRADE
Med-Surg 5:
1) 54 y/o man just arrived to the recovery area after having an upper endoscopy.
Which information collected by the nurse is most important to communicate to
the health care provider?
• Oral temperature of 101.6 F (Fever)
• The client is lethargic and drowsy (Wrong)
• A apical pulse of 104 beats per minute
• Client reports a sore throat (Infection)
Rationale: A temperature elevation may indicate that a perforation has occurred.
The other assessment data are normal immediately after the procedure.
2) Which test is appropriate to perform when screening for this client’s risk for
stroke: (SATA)
• The CHL Cholesterol levels
• The Blood Pressure
• Routine Urinalysis
• Stool specimen
• Blood Sugar Levels
Book: CHART 67-1 Modifiable Risk Factors: Ischemic Stroke pg 1976
3) A 72 y/o client has a history of transit ischemic attack (TIA) has an order for
aspirin 60 mg daily. When the nurse is administering the medication, the client
says, “I don’t need the aspirin today, I don’t have a fever.” Which action should
the nurse take? (Also for Antiplatelet)
• Explain that the aspirin is ordered to decrease stroke risk.
• Tell the client that the aspirin is used to prevent a fever.
• Call the health care provider to clarify the medication order.
• Document that the aspirin was refuse by the client. (Wrong)
Aspirin is ordered to prevent stroke in patients who have experienced TIAs.
Documentation of the patient's refusal to take the medication is an inadequate
response by the nurse. There is no need to clarify the order with the health care
provider. The aspirin is not ordered to prevent aches and pains.
,Med-Surg EXAM 222 A GRADE
4) After receiving change-of-shift report on the following four clients, which
client should the nurse see first?
• An 50 y/o client has a atrial fibrillation and a new ordered for warfarin
(Coumadin).
• An 30 y/o client with a subarachnoid hemorrhagic 2 days ago who has
nimodipine (nimotol)
• An 40 y/o client who experience a transit ischemic attack (TIA) yesterday
who has a dose of aspirin due. (Wrong)
• An 60 y/o client who has a right sided weakness who has a infusion of tPA
prescribed.
Rationale: tPA needs to be infused within the first few hours after stroke symptoms
start in order to be effective in minimizing brain injury. The other medications
should also be given as quickly as possible, but timing of the medications is not as
critical.
5) A 68 y/o who has been admitted for a possible stroke. Which information
from the assessment indicates that the nurse should consult with the health
care provider before giving the prescribed aspirin?
• The Client has a history of great episodes of right sided of hemiplegia.
(Wrong)
• The Client has a atrial fibrillation.
• The Client has dysphasia.
• The Client reports that symptoms begin with severe headaches. (Was
between both of these)
Rationale: A sudden onset headache is typical of a subarachnoid hemorrhage, and
aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic
attack (TIA) are not contraindications to aspirin use, so the nurse can administer
the aspirin.
6) The client was admitted to the emergency department with right sided facial
drooping. When taking the client history which information would be the most
significant? (Remember FAST, T for timing when it began)
• “When did the facial dropping begin?”
• “Have you had facial dropping in the past?”
, Med-Surg EXAM 222 A GRADE
• “Are you having any pain on the right side of your face?”
• “Do you have family history of stroke?”
7) A 50 y/o man vomiting blood streak fluid is admitted to the hospital with
acute gastritis. To determine for possible risk factors of acute gastritis, the nurse
would ask the client about?
• A history of a large recent weight gain or loss.
• A family history of gastric/colic cancer.
• The used of Non-steroidal inflammatory drugs (NSAIDs).
• The amount of saturated fat in the diet.
8) Which nursing action would be most effective in ensuring daily medication
compliance for a client with mild dementia?
• Having the client’s family member administer the medication.
• Posting reminders to take the medication in the client’s house.
• Setting the medications underneath the medication box.
• Calling the client weekly with a reminder to take the medication.
9) When caring for a patient who has had a stroke, a priority is reducing
Intracranial pressure (ICP). What patient position is most consistent with this
goal?
• Extension of the neck.
• Elevation of the head of the bed.
• Head turned slightly to the right.
• Position changes every 15 minutes while awake.
10) A nurse is caring for a client diagnosed with a hemorrhagic stroke. When
creating this client plan of care what goals should be prioritized?
• Prevent communication or immobility.
• Relieve anxiety and pain.
• Relieve sensory deprivation.
• Maintain and improve cerebral tissue perfusion.
11) The nurse will anticipate preparing a sendioone on a old female client who is
vomiting “coffee ground” emesis for.
Med-Surg 5:
1) 54 y/o man just arrived to the recovery area after having an upper endoscopy.
Which information collected by the nurse is most important to communicate to
the health care provider?
• Oral temperature of 101.6 F (Fever)
• The client is lethargic and drowsy (Wrong)
• A apical pulse of 104 beats per minute
• Client reports a sore throat (Infection)
Rationale: A temperature elevation may indicate that a perforation has occurred.
The other assessment data are normal immediately after the procedure.
2) Which test is appropriate to perform when screening for this client’s risk for
stroke: (SATA)
• The CHL Cholesterol levels
• The Blood Pressure
• Routine Urinalysis
• Stool specimen
• Blood Sugar Levels
Book: CHART 67-1 Modifiable Risk Factors: Ischemic Stroke pg 1976
3) A 72 y/o client has a history of transit ischemic attack (TIA) has an order for
aspirin 60 mg daily. When the nurse is administering the medication, the client
says, “I don’t need the aspirin today, I don’t have a fever.” Which action should
the nurse take? (Also for Antiplatelet)
• Explain that the aspirin is ordered to decrease stroke risk.
• Tell the client that the aspirin is used to prevent a fever.
• Call the health care provider to clarify the medication order.
• Document that the aspirin was refuse by the client. (Wrong)
Aspirin is ordered to prevent stroke in patients who have experienced TIAs.
Documentation of the patient's refusal to take the medication is an inadequate
response by the nurse. There is no need to clarify the order with the health care
provider. The aspirin is not ordered to prevent aches and pains.
,Med-Surg EXAM 222 A GRADE
4) After receiving change-of-shift report on the following four clients, which
client should the nurse see first?
• An 50 y/o client has a atrial fibrillation and a new ordered for warfarin
(Coumadin).
• An 30 y/o client with a subarachnoid hemorrhagic 2 days ago who has
nimodipine (nimotol)
• An 40 y/o client who experience a transit ischemic attack (TIA) yesterday
who has a dose of aspirin due. (Wrong)
• An 60 y/o client who has a right sided weakness who has a infusion of tPA
prescribed.
Rationale: tPA needs to be infused within the first few hours after stroke symptoms
start in order to be effective in minimizing brain injury. The other medications
should also be given as quickly as possible, but timing of the medications is not as
critical.
5) A 68 y/o who has been admitted for a possible stroke. Which information
from the assessment indicates that the nurse should consult with the health
care provider before giving the prescribed aspirin?
• The Client has a history of great episodes of right sided of hemiplegia.
(Wrong)
• The Client has a atrial fibrillation.
• The Client has dysphasia.
• The Client reports that symptoms begin with severe headaches. (Was
between both of these)
Rationale: A sudden onset headache is typical of a subarachnoid hemorrhage, and
aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic
attack (TIA) are not contraindications to aspirin use, so the nurse can administer
the aspirin.
6) The client was admitted to the emergency department with right sided facial
drooping. When taking the client history which information would be the most
significant? (Remember FAST, T for timing when it began)
• “When did the facial dropping begin?”
• “Have you had facial dropping in the past?”
, Med-Surg EXAM 222 A GRADE
• “Are you having any pain on the right side of your face?”
• “Do you have family history of stroke?”
7) A 50 y/o man vomiting blood streak fluid is admitted to the hospital with
acute gastritis. To determine for possible risk factors of acute gastritis, the nurse
would ask the client about?
• A history of a large recent weight gain or loss.
• A family history of gastric/colic cancer.
• The used of Non-steroidal inflammatory drugs (NSAIDs).
• The amount of saturated fat in the diet.
8) Which nursing action would be most effective in ensuring daily medication
compliance for a client with mild dementia?
• Having the client’s family member administer the medication.
• Posting reminders to take the medication in the client’s house.
• Setting the medications underneath the medication box.
• Calling the client weekly with a reminder to take the medication.
9) When caring for a patient who has had a stroke, a priority is reducing
Intracranial pressure (ICP). What patient position is most consistent with this
goal?
• Extension of the neck.
• Elevation of the head of the bed.
• Head turned slightly to the right.
• Position changes every 15 minutes while awake.
10) A nurse is caring for a client diagnosed with a hemorrhagic stroke. When
creating this client plan of care what goals should be prioritized?
• Prevent communication or immobility.
• Relieve anxiety and pain.
• Relieve sensory deprivation.
• Maintain and improve cerebral tissue perfusion.
11) The nurse will anticipate preparing a sendioone on a old female client who is
vomiting “coffee ground” emesis for.
