Stuvia-1542971-med-surg-exam-2022-a-grade

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