HESI Med Surg Final Exam Questions and Answers Latest
() (Verified Answers)
priority RN interventions to include in post stroke pts plan of care [SATA]
- treatment with what meds ... what labs to do w/ this treatment
- how often to assess neuro status
- HOB should be
- BG should elevated how often? - ANSWER-- PTT / INR [heparin or coumadin
treatment]
- assess neuro status q 1 hours
- keep HOB elevated
- monitor blood glucose daily
why monitoring BG on post stroke pts - ANSWER-- hyperglycemia associated w/
poor neurologic outcomes in acute strokes pts
- glucose levels > 140 should be treated
RN monitoring post stroke pt. which finding would require inmmediate intervention
by the RN
- O2 sat reading where
- K+ is what?
,- glucose is what? - ANSWER-- pulse ox reading 90% for the past two hours
- serum K+ = 3.0
- serum glucose 150
normal cardiac output to ensure cerebral blood flow and O2 delivery - ANSWER-4-
8 L/min
post stroke pt w/ decreased Cardiac output. HCP needs to be notified regarding
decreased cardiac output to decide whether to initiate IV fluid if hypovolemia is
suspected. which RN intervention would be a priority?
- LOC should be
- how often to monitor I/Os
- capillary refill should monitored how often?
- VS how oten? - ANSWER-- monitor LOC
- monitor I/Os q 1 hours
- monitor capillary refill q 2-4 hours
- monitor pulse oximetry
- VS q 1-2 hours
thrombolytic therapy contraindications for post stroke pts
- initiate within how many hours of the start of symptoms - ANSWER-- pts w/
symptom onset longer than 3 hours prior to admission
,- must be initiatited within 3 hours of the onset of symptoms
pt w/ left sided paralysis has facial drooping with dysphagia, left visual field
deficit and aphasia. which RN diagnosis has the highest priority - ANSWER--
impaired swallowing
[maslows hierarchy of need - physiological needs should be addressed first]
- pt is at risk for asp
pt trouble w/ using left arm. which RN intervention should the RN implement to
address self care deficit
- what to use when the pt is eating - why? - ANSWER-- use plate guards when pt is
eating [prevent food from being pushed off the plate - this will encourage
independence]
modifiable risk factors for stroke
- history of what heart condition - ANSWER-- high cholesterol levels
- diet
- lifestyle
- history of AFib
- smoking
How can AFib lead to seizures
, - predisposes the pt to formation of what
- why is it modifiable... because it can be treated w/ - ANSWER-- Afib = heart
disease
- can predispose the client to clot formation on the wall of the heart or valve
leaflets
- treated w/ medication [modifiable]
STROKE
pt slurred speech and frightened. which clinical manifestations should the RN
expect to find if symptoms are caused by a stroke
- bruit where
- BP is
- DTR are
- vision is aka - ANSWER-- carotid bruit
- elevated BP
- hyporeflexic Deep tendon reflexes
- doplopia [double vision]
why do hyporeflexic deep reflexes occur in a stroke - ANSWER-- d/t to initial
flaccid paralysis resulting in hyporeflexic DTH
() (Verified Answers)
priority RN interventions to include in post stroke pts plan of care [SATA]
- treatment with what meds ... what labs to do w/ this treatment
- how often to assess neuro status
- HOB should be
- BG should elevated how often? - ANSWER-- PTT / INR [heparin or coumadin
treatment]
- assess neuro status q 1 hours
- keep HOB elevated
- monitor blood glucose daily
why monitoring BG on post stroke pts - ANSWER-- hyperglycemia associated w/
poor neurologic outcomes in acute strokes pts
- glucose levels > 140 should be treated
RN monitoring post stroke pt. which finding would require inmmediate intervention
by the RN
- O2 sat reading where
- K+ is what?
,- glucose is what? - ANSWER-- pulse ox reading 90% for the past two hours
- serum K+ = 3.0
- serum glucose 150
normal cardiac output to ensure cerebral blood flow and O2 delivery - ANSWER-4-
8 L/min
post stroke pt w/ decreased Cardiac output. HCP needs to be notified regarding
decreased cardiac output to decide whether to initiate IV fluid if hypovolemia is
suspected. which RN intervention would be a priority?
- LOC should be
- how often to monitor I/Os
- capillary refill should monitored how often?
- VS how oten? - ANSWER-- monitor LOC
- monitor I/Os q 1 hours
- monitor capillary refill q 2-4 hours
- monitor pulse oximetry
- VS q 1-2 hours
thrombolytic therapy contraindications for post stroke pts
- initiate within how many hours of the start of symptoms - ANSWER-- pts w/
symptom onset longer than 3 hours prior to admission
,- must be initiatited within 3 hours of the onset of symptoms
pt w/ left sided paralysis has facial drooping with dysphagia, left visual field
deficit and aphasia. which RN diagnosis has the highest priority - ANSWER--
impaired swallowing
[maslows hierarchy of need - physiological needs should be addressed first]
- pt is at risk for asp
pt trouble w/ using left arm. which RN intervention should the RN implement to
address self care deficit
- what to use when the pt is eating - why? - ANSWER-- use plate guards when pt is
eating [prevent food from being pushed off the plate - this will encourage
independence]
modifiable risk factors for stroke
- history of what heart condition - ANSWER-- high cholesterol levels
- diet
- lifestyle
- history of AFib
- smoking
How can AFib lead to seizures
, - predisposes the pt to formation of what
- why is it modifiable... because it can be treated w/ - ANSWER-- Afib = heart
disease
- can predispose the client to clot formation on the wall of the heart or valve
leaflets
- treated w/ medication [modifiable]
STROKE
pt slurred speech and frightened. which clinical manifestations should the RN
expect to find if symptoms are caused by a stroke
- bruit where
- BP is
- DTR are
- vision is aka - ANSWER-- carotid bruit
- elevated BP
- hyporeflexic Deep tendon reflexes
- doplopia [double vision]
why do hyporeflexic deep reflexes occur in a stroke - ANSWER-- d/t to initial
flaccid paralysis resulting in hyporeflexic DTH
