Nur 242 exam 4 Medical-
u u u u
Surgical Nursing Exam | Questions and Verified Answers| 1
u u u u u u u u
00% Correct| Grade A-Galen
u u u u
uTheuregisteredunurseu(RN)uisucaringuforuauclientuwhouisucurrentlyuhospitalizeduforuaustrok
e.uWhichuprofessionalumanagementustrategyuwillubeumostueffectiveuforutheuRNutouimprove
utheusafetyuanduqualityuofuclientucare?u-uANSWERuDelegation
uTheuclientutakinguintravenousucoagulantumedicationsuforuaubleedingudisorderusuddenlyud
evelopsuanuembolicustrokeuasuauresultuofumedicationuoverdose.uWhichuactionsubyutheuho
spitalumanagementudoesutheuLeapfroguGroupusuggest?uSelectualluthatuapply.uOne,usom
e,uorualluresponsesumayubeucorrect.u-
uANSWERuApologizeutoutheuclientuandufamily.uWaiveuallucostsudirectlyurelatedutoutheuadv
erseueffect.
ReportutheuadverseueventutouTheuJointuCommission.
some,uorualluresponsesumayubeucorrect.u-
uANSWERuSlowuperformance uanducautionu Impaireduspeech/languageuaphasias
Awarenessuofudeficitsuwithudepressionuanduanxiety
uWhenuauclientuhasudifficultyuswallowinguafteruaustroke,uwhichuactionubyutheunurseuwouldubeu
mostuimportantuinupreventingupneumonia?u-
uANSWERuHavingusuctionuavailableuduringumeals
uAuclientuhasuhaduaurecentubrainuattacku(cerebrovascularuaccident/stroke).uWhichuprevent
ativeuwouldutheunurseuanticipateuwillubeuprescribedudailyutouavoidustrainingudueutouconstipat
ion?u-uANSWERuStoolusoftener
uWhichuinterventionuwouldutheudisasterumanagementuteamunurseuperformuforutheusurviv
orsuofuanuexplosionuwhoudevelopeduheatustroke?u-
uANSWERuApplyuiceupacksuonu theuclient'suscalp
Whichuleveluofucareuisutheunurseuprovidinguwhenupreparingutoudischargeuauclientuwhouisulear
u
ningutouwalkuagainuafteruaustrokeutouaurehabilitationucenter?u-uANSWERutertiaryucare
uWhichuactionubyutheuemergencyudepartmentunurseuisutheupriorityuforuauclientuwithuheatust
roke?u-uANSWERuAssessutheuairwayuandubreathing
Auclientuwhousustainsuaustrokeuhasuaulossuofuproprioceptionuandufineutouch.uWhichuarteryuw
u
ouldutheunurseususpectuisudamaged?u-uANSWERuAnteriorucerebral
,uAuclientuhasuaubrainuattacku(stroke)uthatuinvolvesutheurightucerebralucortexuanducranialun
erves.uWhichuareasuofuparalysisuwouldutheunurseuexpectutoufinduuponuassessment?uSele
ctualluthatuapply.uOne,usome,uorualluresponsesumayubeucorrect.u-
uANSWERuLeftulegu Leftuarm
Leftusideuofuface
uInitiallyuafteruaustroke,utheuclient'supupilsuareuequaluandureactiveutoulight.uFouruhoursulater,uthe
unurseuidentifiesuthatuoneupupilureactsumoreuslowlyuthanutheuotheruandutheuclient'susystolicubl
oodupressureuisuincreasing.uForuwhichuconditionuwouldutheunurseuprepareutouintervene?u-
uANSWERuIncreaseduintracranialupressure
uTheunurseuobservesudorsiflexionuofutheubigutoeuandufanninguofuotherutoesuwhenutheula
teralusideuofuauclient'sufootuisustroked.uWhichufindinguwouldutheunurseudocument?u-
ANSWERuExhibitsuaupositiveuBabinskiusign
u
uTheunurseuisucaringuforuauclientuwhouhaduaustrokeuanduwhouhasuvaryingumoodsurangingufromu
angerutoudepressionutouconcernuaboututheuaphasia,uhemiparesis,uandutheugavageufeedings.u
Whichubehavioruindicatesutheuclient'suacceptanceuofuphysicalulimitations?u-
uANSWERuPerformsutubeufeedingsuwithoutuassistance
Auclientuhasudysarthriauafteruaustroke.uWhichugoaluwouldutheunurseuincludeuinutheuplanuofuc
u
areutouaddressuthisuproblem?u-uANSWERuEffectiveucommunication
Whichureflexuisutheunurseutestinguwhenuusinguaudulluobjectutoustrokeufromutheulateralusoleuof
u
auclient'sufootuupwardutoutheugreatutoe?u-uANSWERuBabinski
u
uAuclientuadmittedutoutheuhospitaluwithutheudiagnosisuofuauright-
sidedu"brainuattack"u(stroke)uisuright-
handed.uWhichutaskuwillubeumostudifficultuforuthisuclient?u-
uANSWERu Dressingueveryumorning
uTheunurseuassesseduauclientuwhouexperienceduaurecentubrainuattacku(stroke)uanduhasuaur
esidualuright-
sideduhemiplegia.uWhichurationaleuexplainsutheuimportanceuofutheunurseuidentifyingumobil
ityurestrictionsuoruneuromuscularuabnormalitiesuwhenuassessinguthisuclient?u-
uANSWERuShorteninguandueventualuatrophyuofutheuaffectedumusclesuwilluoccur
Whichuconditionuofuauclientuwithuhemorrhagicustrokeuresultingufromuaumotorubikeuaccidentur
u
equiresuimmediateuattention?u-uANSWERuBodyutemperatureuofu81.2°F
Inuwhichuorderuwouldutheunurseucaringuforuauclientusufferingufromuheatstrokeuprovideue
u
mergencyuinterventions?u-uANSWERuEnsureuaupatentuairway.
Removeutheuclientufromutheuhotuenvironment.u
Removeutheuclient'suclothing
Pouruorusprayucolduwateruonutheuclient'subodyuanduscalp.uF
anutheuclientuwithunewspapersuoruwhateveruisuavailable.
Placeuiceuinuclothuorubagsuandupositionutheupacksuonutheuclient'suscalp
, Emergencyucareushouldubeuprovidedutoutheuclientuwithuheatstrokeutourestoreuthermoregula
tion.uFirstutheunurseuwoulduensureuaupatentuairway.uThenutheunurseuwoulduremoveutheuclie
ntufromutheuhotuenvironmentuintouairuconditioninguorushadeuanduremoveuhisuoruheruclothing.
uThenutheunurseuwouldupouruorusprayucolduwateruonutheuclient'subodyu anduscalp.uTheuclientu
shouldubeufanneduwithunewspapersuoruwhateveruisuavailable.uThisushouldubeufollowedubyupl
acinguiceuinuclothuorubagsuandupositioningutheupacksuonutheuclient'suscalp.
uWhichupriorityuinterventionsuwouldutheunurseuprovideutoutheuclientuhospitalizeduwithuheat
stroke,uaubodyutemperatureuofu106°F,uanduskinuthatuisuhotuandudry?uSelectualluthatuapply.u
One,usome,uorualluresponsesumayubeucorrectu-uANSWERuRemoveutheuclient'suclothing.
Immerseutheuclientuinucolduwater
uWhichunursinguinterventionuisutheupriorityuforuauclientuwithustrokeuwhouisutransitionedufromuthe
uemergencyudepartmentu(ED)utouotherusettings?u-
uANSWERuAssessingutheuleveluofuconsciousnes
WhichuclientuconditionurequiresuaumediumupriorityuofucareuaccordingutoutheuNationaluIn
u
stitutesuofuHealthuStrokeuScaleu(NIHSS)uscore?u-uANSWERuFacialupalsyuscoreuofu1
uTheunurseuisuaboututouperformuauwounduirrigationuonuauclientuwhouhaduauleftuhemisphericust
rokeu1uyearuago.uWhichuassessmentuisumostuimportantuforutheunurseutouperformubeforeube
ginningutheuirrigation?u-uANSWERupain
uTheubodyutemperatureuofuauclientuwithuheatstrokeuisuaboveu104°Fu(40°C).uWhichuisutheuprior
ityuorderutheunurseuwoulduuseuforucoolingutheuclientusouthatubreathinguanducirculationuareunotui
mpaired?u-uANSWERuTheunurseuwillutakeuoffutheuclient'suclothing.
Theunurseuwoulduplaceuiceupacksuonutheuneck,uaxillae,uchest,uandugroin.uTheu
nurseuwoulduimmerseutheuvictimuinucolduwater.
Theunurseuwouldufanutheuclienturapidlyutouaiduinucoolingubyuevaporation.
Whichuprehospitalucareuinterventionuisutheupriorityuforutheuclientuwithuheatstroke?u-
u
ANSWERuWithholdingufooduoruliquidutoutheuvictim
u
TheuclientuwithuwhichuNationaluInstitutesuofuHealthuStrokeuScaleu(NIHSS)uscoreuwouldubeutre
u
atedufirst?u-uANSWERu3uforufacialupalsy
109uFu-uANSWERu42.8uCu(109-32):5/9
u
Theunurseuisuplanningucareuforuanuimmobilizeduclientuwhouhaduaustrokeuwithuright-
sideduhemiparesis.uWhichuactivityuwouldutheunurseuincludeuinutheuplanuofucare?u-
uANSWERuAssistutheuclientutouperformurange-of-
motionu(ROM)uexercisesueveryu1utou2uhours
Whichuisutheupriorityunursinguactionuforuauclientuadmittedutoutheuhospitaluinuaucomauafteruh
u
avinguaustroke?u-uANSWERuMaintainuanuopenuairway.
u u u u
Surgical Nursing Exam | Questions and Verified Answers| 1
u u u u u u u u
00% Correct| Grade A-Galen
u u u u
uTheuregisteredunurseu(RN)uisucaringuforuauclientuwhouisucurrentlyuhospitalizeduforuaustrok
e.uWhichuprofessionalumanagementustrategyuwillubeumostueffectiveuforutheuRNutouimprove
utheusafetyuanduqualityuofuclientucare?u-uANSWERuDelegation
uTheuclientutakinguintravenousucoagulantumedicationsuforuaubleedingudisorderusuddenlyud
evelopsuanuembolicustrokeuasuauresultuofumedicationuoverdose.uWhichuactionsubyutheuho
spitalumanagementudoesutheuLeapfroguGroupusuggest?uSelectualluthatuapply.uOne,usom
e,uorualluresponsesumayubeucorrect.u-
uANSWERuApologizeutoutheuclientuandufamily.uWaiveuallucostsudirectlyurelatedutoutheuadv
erseueffect.
ReportutheuadverseueventutouTheuJointuCommission.
some,uorualluresponsesumayubeucorrect.u-
uANSWERuSlowuperformance uanducautionu Impaireduspeech/languageuaphasias
Awarenessuofudeficitsuwithudepressionuanduanxiety
uWhenuauclientuhasudifficultyuswallowinguafteruaustroke,uwhichuactionubyutheunurseuwouldubeu
mostuimportantuinupreventingupneumonia?u-
uANSWERuHavingusuctionuavailableuduringumeals
uAuclientuhasuhaduaurecentubrainuattacku(cerebrovascularuaccident/stroke).uWhichuprevent
ativeuwouldutheunurseuanticipateuwillubeuprescribedudailyutouavoidustrainingudueutouconstipat
ion?u-uANSWERuStoolusoftener
uWhichuinterventionuwouldutheudisasterumanagementuteamunurseuperformuforutheusurviv
orsuofuanuexplosionuwhoudevelopeduheatustroke?u-
uANSWERuApplyuiceupacksuonu theuclient'suscalp
Whichuleveluofucareuisutheunurseuprovidinguwhenupreparingutoudischargeuauclientuwhouisulear
u
ningutouwalkuagainuafteruaustrokeutouaurehabilitationucenter?u-uANSWERutertiaryucare
uWhichuactionubyutheuemergencyudepartmentunurseuisutheupriorityuforuauclientuwithuheatust
roke?u-uANSWERuAssessutheuairwayuandubreathing
Auclientuwhousustainsuaustrokeuhasuaulossuofuproprioceptionuandufineutouch.uWhichuarteryuw
u
ouldutheunurseususpectuisudamaged?u-uANSWERuAnteriorucerebral
,uAuclientuhasuaubrainuattacku(stroke)uthatuinvolvesutheurightucerebralucortexuanducranialun
erves.uWhichuareasuofuparalysisuwouldutheunurseuexpectutoufinduuponuassessment?uSele
ctualluthatuapply.uOne,usome,uorualluresponsesumayubeucorrect.u-
uANSWERuLeftulegu Leftuarm
Leftusideuofuface
uInitiallyuafteruaustroke,utheuclient'supupilsuareuequaluandureactiveutoulight.uFouruhoursulater,uthe
unurseuidentifiesuthatuoneupupilureactsumoreuslowlyuthanutheuotheruandutheuclient'susystolicubl
oodupressureuisuincreasing.uForuwhichuconditionuwouldutheunurseuprepareutouintervene?u-
uANSWERuIncreaseduintracranialupressure
uTheunurseuobservesudorsiflexionuofutheubigutoeuandufanninguofuotherutoesuwhenutheula
teralusideuofuauclient'sufootuisustroked.uWhichufindinguwouldutheunurseudocument?u-
ANSWERuExhibitsuaupositiveuBabinskiusign
u
uTheunurseuisucaringuforuauclientuwhouhaduaustrokeuanduwhouhasuvaryingumoodsurangingufromu
angerutoudepressionutouconcernuaboututheuaphasia,uhemiparesis,uandutheugavageufeedings.u
Whichubehavioruindicatesutheuclient'suacceptanceuofuphysicalulimitations?u-
uANSWERuPerformsutubeufeedingsuwithoutuassistance
Auclientuhasudysarthriauafteruaustroke.uWhichugoaluwouldutheunurseuincludeuinutheuplanuofuc
u
areutouaddressuthisuproblem?u-uANSWERuEffectiveucommunication
Whichureflexuisutheunurseutestinguwhenuusinguaudulluobjectutoustrokeufromutheulateralusoleuof
u
auclient'sufootuupwardutoutheugreatutoe?u-uANSWERuBabinski
u
uAuclientuadmittedutoutheuhospitaluwithutheudiagnosisuofuauright-
sidedu"brainuattack"u(stroke)uisuright-
handed.uWhichutaskuwillubeumostudifficultuforuthisuclient?u-
uANSWERu Dressingueveryumorning
uTheunurseuassesseduauclientuwhouexperienceduaurecentubrainuattacku(stroke)uanduhasuaur
esidualuright-
sideduhemiplegia.uWhichurationaleuexplainsutheuimportanceuofutheunurseuidentifyingumobil
ityurestrictionsuoruneuromuscularuabnormalitiesuwhenuassessinguthisuclient?u-
uANSWERuShorteninguandueventualuatrophyuofutheuaffectedumusclesuwilluoccur
Whichuconditionuofuauclientuwithuhemorrhagicustrokeuresultingufromuaumotorubikeuaccidentur
u
equiresuimmediateuattention?u-uANSWERuBodyutemperatureuofu81.2°F
Inuwhichuorderuwouldutheunurseucaringuforuauclientusufferingufromuheatstrokeuprovideue
u
mergencyuinterventions?u-uANSWERuEnsureuaupatentuairway.
Removeutheuclientufromutheuhotuenvironment.u
Removeutheuclient'suclothing
Pouruorusprayucolduwateruonutheuclient'subodyuanduscalp.uF
anutheuclientuwithunewspapersuoruwhateveruisuavailable.
Placeuiceuinuclothuorubagsuandupositionutheupacksuonutheuclient'suscalp
, Emergencyucareushouldubeuprovidedutoutheuclientuwithuheatstrokeutourestoreuthermoregula
tion.uFirstutheunurseuwoulduensureuaupatentuairway.uThenutheunurseuwoulduremoveutheuclie
ntufromutheuhotuenvironmentuintouairuconditioninguorushadeuanduremoveuhisuoruheruclothing.
uThenutheunurseuwouldupouruorusprayucolduwateruonutheuclient'subodyu anduscalp.uTheuclientu
shouldubeufanneduwithunewspapersuoruwhateveruisuavailable.uThisushouldubeufollowedubyupl
acinguiceuinuclothuorubagsuandupositioningutheupacksuonutheuclient'suscalp.
uWhichupriorityuinterventionsuwouldutheunurseuprovideutoutheuclientuhospitalizeduwithuheat
stroke,uaubodyutemperatureuofu106°F,uanduskinuthatuisuhotuandudry?uSelectualluthatuapply.u
One,usome,uorualluresponsesumayubeucorrectu-uANSWERuRemoveutheuclient'suclothing.
Immerseutheuclientuinucolduwater
uWhichunursinguinterventionuisutheupriorityuforuauclientuwithustrokeuwhouisutransitionedufromuthe
uemergencyudepartmentu(ED)utouotherusettings?u-
uANSWERuAssessingutheuleveluofuconsciousnes
WhichuclientuconditionurequiresuaumediumupriorityuofucareuaccordingutoutheuNationaluIn
u
stitutesuofuHealthuStrokeuScaleu(NIHSS)uscore?u-uANSWERuFacialupalsyuscoreuofu1
uTheunurseuisuaboututouperformuauwounduirrigationuonuauclientuwhouhaduauleftuhemisphericust
rokeu1uyearuago.uWhichuassessmentuisumostuimportantuforutheunurseutouperformubeforeube
ginningutheuirrigation?u-uANSWERupain
uTheubodyutemperatureuofuauclientuwithuheatstrokeuisuaboveu104°Fu(40°C).uWhichuisutheuprior
ityuorderutheunurseuwoulduuseuforucoolingutheuclientusouthatubreathinguanducirculationuareunotui
mpaired?u-uANSWERuTheunurseuwillutakeuoffutheuclient'suclothing.
Theunurseuwoulduplaceuiceupacksuonutheuneck,uaxillae,uchest,uandugroin.uTheu
nurseuwoulduimmerseutheuvictimuinucolduwater.
Theunurseuwouldufanutheuclienturapidlyutouaiduinucoolingubyuevaporation.
Whichuprehospitalucareuinterventionuisutheupriorityuforutheuclientuwithuheatstroke?u-
u
ANSWERuWithholdingufooduoruliquidutoutheuvictim
u
TheuclientuwithuwhichuNationaluInstitutesuofuHealthuStrokeuScaleu(NIHSS)uscoreuwouldubeutre
u
atedufirst?u-uANSWERu3uforufacialupalsy
109uFu-uANSWERu42.8uCu(109-32):5/9
u
Theunurseuisuplanningucareuforuanuimmobilizeduclientuwhouhaduaustrokeuwithuright-
sideduhemiparesis.uWhichuactivityuwouldutheunurseuincludeuinutheuplanuofucare?u-
uANSWERuAssistutheuclientutouperformurange-of-
motionu(ROM)uexercisesueveryu1utou2uhours
Whichuisutheupriorityunursinguactionuforuauclientuadmittedutoutheuhospitaluinuaucomauafteruh
u
avinguaustroke?u-uANSWERuMaintainuanuopenuairway.
