Question

The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

Answer 1

Correct Answers:

Evaluate the patient's ability to swallow

Rationale :

🤔Before administering any oral medication, the nurse must assess the patient’s ability to swallow, especially in cases of facial droop or slurred speech which are signs of potential dysphagia.

💊Giving medication to a patient with impaired swallowing increases the risk of aspiration, which can lead to serious respiratory complications.

👄Slurred speech and facial droop can impair coordination of muscles needed for swallowing, making this assessment critical to patient safety.

🧠Only after confirming a safe swallow reflex can oral medications be administered safely.

📌core message

Always assess swallowing ability before giving oral medications to patients with neurologic deficits.

Answer 2

Correct Answers:

You should keep your knees apart using a wedge or pillow.

Rationale :

🧊After hip replacement surgery, preventing dislocation is a top priority, especially in the early post-operative phase.

🪑Maintaining proper hip alignment is crucial; keeping the legs apart using an abduction pillow or wedge helps prevent hip adduction, which could lead to dislocation.

⚠️Patients are advised not to cross their legs or bend the hip beyond 90 degrees. 👩‍⚕️Teaching the client to use positioning aids promotes safe recovery and protects the surgical site.

📌core message

Post-hip replacement patients must avoid hip adduction by using an abduction device to reduce dislocation risk.

Answer 3

Correct Answers:

The patient has the virus but the infection is well controlled and not currently transmissible

Rationale :

📉An undetectable viral load in HIV indicates that the virus is suppressed below the threshold of detection due to effective antiretroviral therapy (ART).

📚This does not mean the virus is gone, but rather that HIV is well controlled, and the patient’s risk of transmission is extremely low.

❌Patients should continue ART even with undetectable levels, as stopping can lead to viral rebound.

🧠Education should reinforce that undetectable means untransmittable (U=U), but not cured.

📌core message

An undetectable viral load means the virus is well controlled and minimally transmissible, not that the patient is cured.

Answer 4

Correct Answers:

Hemoglobin AIC (glycosylated hemoglobin) of 7.2%

Rationale :

🧪A hemoglobin A1C ≥6.5% is one of the diagnostic criteria for diabetes mellitus.

📆This test reflects average blood glucose over the past 2–3 months and is used for both diagnosis and management.

💡A result of 7.2% indicates chronic hyperglycemia, which supports a diagnosis of diabetes.

📚Unlike fasting glucose, A1C is not affected by short-term changes and is useful in outpatient diagnosis.

📌core message

A Hemoglobin A1C ≥6.5% is diagnostic of diabetes, reflecting chronic hyperglycemia.

Answer 5

Correct Answers:

Hemoglobin of 9g/dl

Rationale :

🩸Hemoglobin is a key indicator of oxygen-carrying capacity, and a value of 9 g/dL reflects moderate anemia.

🚩Symptoms like fatigue, pallor, and dizziness directly correlate with low hemoglobin levels, making it a priority concern.

💡Oxygen delivery to tissues becomes impaired at this level, which requires prompt assessment and interventions such as iron therapy or transfusion.

📉Other labs (e.g., potassium, sodium) are within normal range and are not urgent in this context.

📌core message

Low hemoglobin indicates anemia and is a priority when evaluating fatigue and weakness.

Answer 6

Correct Answers:

Preparing a primary and secondary IV tubing

Rationale :

💉Blood transfusions must be administered via specific blood administration sets, not standard primary and secondary tubing.

🧪The correct tubing includes a Y-set with an in-line filter to prevent infusion of clots or debris.

⚠️Using incorrect tubing can result in transfusion complications, including infection or clot formation.

📋Other listed interventions (consent, double check, normal saline) are standard and appropriate.

📌core message

Standard IV tubing is inappropriate for blood transfusion—use a blood administration set with a filter.

Answer 7

Correct Answers:

"I'll be glad when I can stop taking this medicine after my seizures are controlled."

Rationale :

💊Phenytoin is typically prescribed for long-term management of seizure disorders.

📢Patients must be taught that stopping antiepileptic medications suddenly can trigger life-threatening seizures.

📚Discontinuation should only occur under a physician’s guidance after careful evaluation.

🧠This response shows a misunderstanding, indicating a need for further patient education about seizure control.

📌core message

Phenytoin therapy is long-term, and patients must understand it should not be stopped abruptly.

Answer 8

Correct Answers:

You may start taking warfarin while still on Heparin when you are getting ready be discharged home
Use a soft-bristled toothbrush and avoid brushing too aggressively
You should replace straight razors with an electric shaver to avoid cuts

Rationale :

🩸It is common to overlap heparin and warfarin when transitioning to long-term anticoagulation, as warfarin takes days to reach therapeutic levels.

💁‍♂️Soft toothbrushes and electric razors are important to reduce bleeding risk while on anticoagulants.

📛Avoiding injury is key due to warfarin's bleeding risk, and education must focus on bleeding precautions.

⚠️Monitoring INR—not aPTT—is the correct lab test for warfarin, making option B incorrect.

📌core message

Warfarin education should focus on safety measures and understanding the transition from heparin.

Answer 9

Correct Answers:

Patient's refusal to cough, deep breathe, and use their incentive spirometer due to pain.

Rationale :

💁‍♂️Post-operative respiratory exercises are essential to prevent complications like atelectasis and pneumonia.

⚠️Refusal to perform these actions due to pain indicates a risk for hypoventilation and poor oxygen exchange.

💊Pain should be managed effectively to allow participation in deep breathing and incentive spirometry.

📋Delays in respiratory interventions can lead to serious long-term complications, including infection and respiratory failure.

📌core message

Inadequate pulmonary hygiene post-op due to pain-related refusal is a priority risk for complications.

Answer 10

Correct Answers:

Pernicious anemia

Rationale :

🧬Pernicious anemia results from vitamin B12 deficiency, often due to poor absorption from lack of intrinsic factor.

💉Vitamin B12 injections are the treatment of choice, especially when oral absorption is impaired.

🧪Low hemoglobin with neurologic symptoms (e.g., paresthesia) are classic features of B12 deficiency anemia.

📚Other types of anemia (e.g., iron-deficiency, hemolytic) do not typically require B12 administration.

📌core message

Vitamin B12 therapy is specific for pernicious anemia, which involves B12 malabsorption.

Ati n120 med surg exam.

No.

1 :
The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

2 :
Which of the following should be included in patient teaching after hip replacement surgery?

3 :
A patient has Human Immunodeficiency Virus infection and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory study results?

4 :
The nurse in a clinic reviewing laboratory results for a patient suspected of having undiagnosed diabetes mellitus. Which of the following results would be diagnostic for diabetes.

5 :
The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse's priority for planning care?

6 :
Which of the following would not be an appropriate nursing intervention when preparing to administer a blood transfusion?

7 :
A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin, which of following statements by the client indicates a need for further teaching?

8 :
A nurse is providing education for client newly prescribed warfarin in preparation for being discharged home. Which of the following should be included the teaching plan? (Select all that apply.)

9 :
The nurse is assessing a client in the immediate post- operative setting. Which of the following finding requires priority intervention to prevent long-term complications?

10 :
The nurse is preparing to administer a shot of vitamin B12 to a client with low hemoglobin. The nurse knows that this medication is most indicative of which type of anemia?

Ati n120 med surg exam.

No.

1 : The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

2 : Which of the following should be included in patient teaching after hip replacement surgery?

3 : A patient has Human Immunodeficiency Virus infection and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory study results?

4 : The nurse in a clinic reviewing laboratory results for a patient suspected of having undiagnosed diabetes mellitus. Which of the following results would be diagnostic for diabetes.

5 : The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse's priority for planning care?

6 : Which of the following would not be an appropriate nursing intervention when preparing to administer a blood transfusion?

7 : A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin, which of following statements by the client indicates a need for further teaching?

8 : A nurse is providing education for client newly prescribed warfarin in preparation for being discharged home. Which of the following should be included the teaching plan? (Select all that apply.)

9 : The nurse is assessing a client in the immediate post- operative setting. Which of the following finding requires priority intervention to prevent long-term complications?

10 : The nurse is preparing to administer a shot of vitamin B12 to a client with low hemoglobin. The nurse knows that this medication is most indicative of which type of anemia?

1 :
The nurse is caring for a client in the emergency department who is experiencing facial droop and slurred speech orally. The physician ordered aspirin to be given orally. What should the nurse do?

2 :
Which of the following should be included in patient teaching after hip replacement surgery?

3 :
A patient has Human Immunodeficiency Virus infection and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory study results?

4 :
The nurse in a clinic reviewing laboratory results for a patient suspected of having undiagnosed diabetes mellitus. Which of the following results would be diagnostic for diabetes.

5 :
The nurse cares for a client who is a pale and reports frequent fatigue, weakness and dizziness. Which serum laboratory test result is the nurse's priority for planning care?

6 :
Which of the following would not be an appropriate nursing intervention when preparing to administer a blood transfusion?

7 :
A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin, which of following statements by the client indicates a need for further teaching?

8 :
A nurse is providing education for client newly prescribed warfarin in preparation for being discharged home. Which of the following should be included the teaching plan? (Select all that apply.)

9 :
The nurse is assessing a client in the immediate post- operative setting. Which of the following finding requires priority intervention to prevent long-term complications?

10 :
The nurse is preparing to administer a shot of vitamin B12 to a client with low hemoglobin. The nurse knows that this medication is most indicative of which type of anemia?