NURSING CARE MANAGEMENT 103 (RLE) EVALUATION EXAM OSPITAL NG MUNTINLUPA

Name: _________________________________ Group, Yr. & Section: _____________________ Cerebrovascular Accident:

Clinical Instructor: ___________________________ Date: _____________________________________

5. 1. A 78- year- old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? a. Prepare to administer recombinant tissue plasminogen activator (rt- PA). b. Discuss the precipitating factors that caused the symptoms. c. Schedule for STAT CT scan of head. d. Notify the speech pathologist for an emergency consult. The nurse is assessing a client is experiencing motor loss as a result of a left sided CVA. Which clinical manifestations would the nurse document? a. Hemiparesis of the client s left arm and apraxia. b. Paralysis of the right side of the body and ataxia. c. Homonymous hemianopsia and diplopia. d. Impulsive behavior and hostility toward family. The client is diagnosed with a right- sided CVA is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply: a. Position the client to prevent shoulder adduction. b. Turn and reposition the client every shift. c. Encourage the client to move the affected side. d. Perform quadriceps exercises three (3) times a day. e. Instruct the client to hold the fingers in a fist. The nurse is planning care for a client experiencing agnosia secondary to a CVA. Which collaborative management will be included in the plan of care? a. Observing the client swallowing for possible aspiration. b. Positioning the client in a semi- Fowler s position when sleeping. c. Placing a suction set- up at the client s bedside during meals. d. Referring the client to an occupational therapist for evaluation.

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? a. An oral anticoagulant medication. b. A beta- blocker medication. c. An anti- hyperurecemic medication. d. A thrombolytic medication. The client has been diagnosed with a CVA. The client s wife is concerned about her husband s generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? a. Obtain a rubber mat to place under the dinner plate. b. Purchase a long- handled bath sponge for showering. c. Purchase clothes with Velcro closure devices. d. Obtain a raised toilet seat for the client s bathroom. The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? a. Potential for Injury. b. Powerlessness. c. Disturbed thought process. d. Sexual dysfunction. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? a. A blood glucose level of 480 mg/ dL. b. A right- sided carotid bruit. c. A blood pressure of 220/ 120 mmHg. d. The presence of bronchogenic carcinoma. The 85- year- old diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? a. Administer a non- narcotic medication. b. Prepare STAT MRI. c. Start IV with D5W at 100 mL/ hr. d. Complete neurological assessment.

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10. A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? a. Administer a stool softener. b. Encourage the client to cough hourly. c. Monitor neurological status every shift. d. Maintain the dopamine drip to keep BP at 160/ 90 mmHg. Blood Transfusions 11. The client has a hematocrit of 22.3% and hemoglobin of 7.7 mg/dL. The health care professional (HCP) has ordered of 2 untis of PRBC to be transfused. Which interventions should the nurse implement? Select all that apply: a. Obtain a signed consent. b. Initiate a 22- gauge IV. c. Assess the client s lungs. d. Check for allergies. e. Hang a keep- open IV of D5Nss. 12. The client is admitted to the emergency department after motor- vehicle accident. The nurse notes profuse bleeding from a right- sided abdominal injury. Which intervention should the nurse implement? a. Type and cross-match for red blood cells immediately (STAT). b. Initiate an IV with a #18-gauge needle and hang NS. c. Have the client a sign consent for an exploratory laparatomy. d. Notify the significant other of the client s admission. 13. The nurse is working on a blood bank Facility procuring units of blood from donors. Which client would not be a candidate to donate blood? a. The client who had wisdom teeth removed a week ago. b. The nursing student who received a measles immunization 2 months ago. c. The mother with a six (6)-week old newborn. d. The client who developed an allergy to aspirin in childhood. 14. The client with O+ blood is in need of an emergency of transfusion but the lab does not have any O+ blood available. Which potential unit of blood could be given to the client ? a. The O- unit. b. The A+ unit. c. The B+ unit. d. Any Rh+ unit.

15. The client is scheduled to have a total hip replacement in two (2) months and has chosen to prepare for autologous transfusions. Which medication would the nurse administer to prepare the clent. a. Prednisone, a glucocorticoid. b. Zithromax, an antibiotic. c. Ativan, a tranquilizer d. Epogen, a biologic response modifier. 16. The client undergoing knee replacement surgery has a cell-saver apparatus attached to the knee when he arrives in the post-anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system ? a. Infuse the drainage into the client when a prescribed amount fills the chamber. b. Attached an hourly drainage collection bag to the unit and discard the drainage. c. Replace the unit with a continuous passive motion unit and start it on low. d. Have another nurse verify the unit number prior to reinfusing the blood. 17. Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours ? a. The blood will coagulate if left out of the refrigerator for longer than four (4) hours. b. The blood has potential bacteria growth if allowed to infuse longer. c. The blood components begin to break down after four (4) hours. d. The blood will not be affected; this is a laboratory procedure. 18. The HCP orders two (2) units of blood to be administered over eight (8) hours each for a diagnosed with heart failure. Which intervention(s) should the nurse take ? a. Call the HCP to question the order because blood must infuse within four (4) hours. b. Retrieve the blood from the laboratory and run each unit at an eight (8) hour rate. c. Notify the lab to split each unit into half units and infuse each half for four (4) hours. d. Infuse each unit for four (4) hours, the maximum rate for a unit of blood. 19. The client receiving a unit of PRBCs begin to chill and develop hives. Which action should be the nurse s first response ? a. Notify the laboratory and health-care provider. b. Administer the histamine-1 blocker, Benadryl, IV. c. Assess the client for further complications. d. Stop the transfusion and change the tubing at the hub.

20. The nurse and unlicensed nursing assistant are caring for clients on an oncology floor. Which nursing task would be delegated to the unlicensed nursing assistant ? a. Assess the urine output on a client who has a blood transfusion reaction. b. Take the first fifteen (15) minutes of vital signs on a client receiving a PRCBs. c. Auscultate the lung sounds of a cliiet transfusion. d. Assist a client who recieved ten (10) units of platelets in brushing teeth. 21. The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first ? a. The client is two-thirds of the way through blood transfusions and has no complains of dyspnea or hives. b. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body. c. The client with peptic ulcer disease who called over intercom to say that he is vomiting blood. d. The client diagnosed with Crohn s disease who is complaining of perineal disease discomfort. 22. The client received two (2) units of packed red blood cells of 250 mL with 63 mL of preservative each during the shift. There was 240 mL of saline remaining in the 500 mL bag when then the nurse discarded the blood tubing. How may milliliters of fluid should be documented on the intake and output record ? _________________ Peptic Ulcer Disease 23. Which assessment data support the client s diagnosis of gastric ulcer? a. Presence of blood in the clients stool for the past month. b. Complaints of a burning sensation that moves like a wave. c. Sharp pain in the upper abdomen after eating a heavy meal. d. Comparison of complaints of pain with ingestion of food and sleep. 24. The client diagnosis