Question

A nurse is providing education of enoxaparin to a patient diagnosed with deep venous thrombosis. Which statement by the patient indicates understanding of the teaching?

Answer 1

Correct Answers:

"This medication will keep the blood clot from growing larger."

Rationale :

✅ Enoxaparin is a low molecular weight heparin (LMWH) used to prevent clot extension and formation.

✅ It does not dissolve existing clots, but stabilizes them and prevents embolization.

✅ By inhibiting factor Xa, it slows clotting without fully blocking coagulation.

✅ It is commonly given subcutaneously, not IV.

✅ The goal is to reduce the risk of DVT progression or PE.

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Answer 2

Correct Answers:

Assess nutritional status with height, weight, blood urea nitrogen, transferrin, hemoglobin and hematocrit level.

Rationale :

✴️ In a patient with HIV and 6 days of diarrhea and vomiting, the nurse’s priority is to assess for dehydration and malnutrition.

✴️ These symptoms increase the risk of fluid and electrolyte imbalance.

✴️ Assessing BUN, Hct, transferrin, and weight guides rehydration and nutrition support.

✴️ Without this assessment, subsequent interventions may be unsafe or ineffective.

✴️ Nutritional assessment should precede referrals or meal planning.

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Answer 3

Correct Answers:

Encourages the patient to perform cough, deep breathing, postural drainage every 2 to 4 hours.

Rationale :

🔹 Airway clearance techniques are critical in patients with HIV and pneumonia.

🔹 Regular coughing and postural drainage prevent atelectasis and improve ventilation.

🔹 Pneumonia compromises alveolar gas exchange, especially in immunosuppressed clients.

🔹 Deep breathing expands lungs and mobilizes secretions.

🔹 Non-pharmacologic pulmonary hygiene supports recovery and reduces hypoxia.

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Answer 4

Correct Answers:

"Warfarin takes several days to work, so the heparin will be used until the warfarin reaches a therapeutic level."

Rationale :

🟢 Warfarin requires 3–5 days to achieve therapeutic INR (2–3).

🟢 Heparin provides immediate anticoagulation, so both drugs are given simultaneously.

🟢 Heparin is discontinued only when INR reaches therapeutic range.

🟢 They do not dissolve clots, but prevent clot propagation.

🟢 This overlap is essential to avoid subtherapeutic anticoagulation gaps.

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Answer 5

Correct Answers:

Let your provider know if a new cough occurs

Rationale :

🔸 Lisinopril is an ACE inhibitor, and a dry, persistent cough is a known adverse effect.

🔸 This occurs due to accumulation of bradykinin.

🔸 The cough may be non-productive and can impair quality of life.

🔸 Patients should report new symptoms to assess for possible drug substitution (e.g., ARB).

🔸 High potassium diets are not recommended with ACE inhibitors due to hyperkalemia risk.

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Answer 6

Correct Answers:

Tenderness in the thigh.

Rationale :

🔵 Deep vein thrombosis often presents with thigh/calf tenderness, swelling, and warmth.

🔵 Pain occurs due to inflammation and venous obstruction.

🔵 Other signs may include erythema or unilateral edema.

🔵 Loss of hair or bruits are arterial signs, not venous.

🔵 Early detection helps prevent pulmonary embolism.

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Answer 7

Correct Answers:

"Have you recently had unprotected Intercourse with a new partner?"

Rationale :

🟣 Unprotected sex with a new partner is a high-risk behavior for HIV transmission.

🟣 Early symptoms of HIV include flu-like illness, lymphadenopathy, and sore throat.

🟣 Targeted sexual history helps with early diagnosis and timely antiretroviral therapy.

🟣 Nonjudgmental, open-ended questions improve patient trust and disclosure.

🟣 Other questions (alcohol, immunizations) are unrelated to HIV risk in this context.

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Answer 8

Correct Answers:

Fecal-oral

Rationale :

🔶 Hepatitis E is transmitted via fecal-oral route, often through contaminated water.

🔶 It is endemic in areas with poor sanitation and water treatment.

🔶 Sexual or blood-borne routes are not typical for Hepatitis E.

🔶 Education focuses on hand hygiene, water boiling, and safe food handling.

🔶 Pregnant women are at high risk for complications with HEV.

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Answer 9

Correct Answers:

Use the doppler ultrasound to detect pedal pulses

Rationale :

🔴 When pedal pulses are nonpalpable, Doppler ultrasound is the standard next step.

🔴 It helps assess arterial perfusion noninvasively.

🔴 Tourniquets and elevation can worsen ischemia.

🔴 Early identification helps prevent tissue necrosis and limb loss.

🔴 Accurate vascular assessment is critical in patients with PAD or arterial occlusion.

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Answer 10

Correct Answers:

Cereals
Citrus fruits
Almonds

Rationale :

⚫ Cereals and Citrus fruits are rich in fiber and potassium, which support blood pressure control.

⚫ Almonds provide healthy fats and magnesium, also beneficial in the DASH diet.

⚫ Whole milk and pork are higher in sodium and saturated fats, not DASH-friendly.

⚫ The DASH diet focuses on fruits, vegetables, lean proteins, and low-fat dairy to lower hypertension risk.

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MED SURG EXAM MONTGOMERY college

No.

1 :
A nurse is providing education of enoxaparin to a patient diagnosed with deep venous thrombosis. Which statement by the patient indicates understanding of the teaching?

2 :
The nurse admits a patient with a history of human immunodeficiency virus (HIV). Patient reports severe diarrhea, vomiting for the past 6 days. Which action will the nurse perform first?

3 :
A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?

5 :
The nurse is caring for a patient who was recently placed on lisinopril to control hypertension. What teaching will the nurse provide?

6 :
A nurse is assessing a patient diagnosed with deep-vein thrombosis. Which clinical manifestation is consistent with the diagnosis?

7 :
A nurse is assessing a patient who is presented with flu-like symptoms. Assessment reveals the presence of fever, sore throat, enlarged neck lymphatic nodes. What assessment question addresses the possible etiology of human immunodeficiency virus?

8 :
A patient with hepatitis E is admitted to a medical-surgical unit. The nurse teaches the patient and their family that this type of hepatitis spread through which mode of transmission?

9 :
During the assessment of the patient, the nurse finds nonpalpable pedal pulses in the affected leg. How will the nurse proceed with assessment?

10 :
The nurse is reviewing dietary approaches to stop hypertension diet (DASH) with a patient who had been diagnosed with hypertension. The nurse explains that the DASH diet includes which food options? Select All That Apply

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MED SURG EXAM MONTGOMERY college

No.

1 : A nurse is providing education of enoxaparin to a patient diagnosed with deep venous thrombosis. Which statement by the patient indicates understanding of the teaching?

2 : The nurse admits a patient with a history of human immunodeficiency virus (HIV). Patient reports severe diarrhea, vomiting for the past 6 days. Which action will the nurse perform first?

3 : A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?

5 : The nurse is caring for a patient who was recently placed on lisinopril to control hypertension. What teaching will the nurse provide?

6 : A nurse is assessing a patient diagnosed with deep-vein thrombosis. Which clinical manifestation is consistent with the diagnosis?

7 : A nurse is assessing a patient who is presented with flu-like symptoms. Assessment reveals the presence of fever, sore throat, enlarged neck lymphatic nodes. What assessment question addresses the possible etiology of human immunodeficiency virus?

8 : A patient with hepatitis E is admitted to a medical-surgical unit. The nurse teaches the patient and their family that this type of hepatitis spread through which mode of transmission?

9 : During the assessment of the patient, the nurse finds nonpalpable pedal pulses in the affected leg. How will the nurse proceed with assessment?

10 : The nurse is reviewing dietary approaches to stop hypertension diet (DASH) with a patient who had been diagnosed with hypertension. The nurse explains that the DASH diet includes which food options? Select All That Apply

1 :
A nurse is providing education of enoxaparin to a patient diagnosed with deep venous thrombosis. Which statement by the patient indicates understanding of the teaching?

2 :
The nurse admits a patient with a history of human immunodeficiency virus (HIV). Patient reports severe diarrhea, vomiting for the past 6 days. Which action will the nurse perform first?

3 :
A nurse is assessing a patient who has a history of human immunodeficiency virus (HIV) and has been admitted with pneumonia. Which intervention will the nurse perform to ensure the patient exhibits clear breath sounds?

5 :
The nurse is caring for a patient who was recently placed on lisinopril to control hypertension. What teaching will the nurse provide?

6 :
A nurse is assessing a patient diagnosed with deep-vein thrombosis. Which clinical manifestation is consistent with the diagnosis?

7 :
A nurse is assessing a patient who is presented with flu-like symptoms. Assessment reveals the presence of fever, sore throat, enlarged neck lymphatic nodes. What assessment question addresses the possible etiology of human immunodeficiency virus?

8 :
A patient with hepatitis E is admitted to a medical-surgical unit. The nurse teaches the patient and their family that this type of hepatitis spread through which mode of transmission?

9 :
During the assessment of the patient, the nurse finds nonpalpable pedal pulses in the affected leg. How will the nurse proceed with assessment?

10 :
The nurse is reviewing dietary approaches to stop hypertension diet (DASH) with a patient who had been diagnosed with hypertension. The nurse explains that the DASH diet includes which food options? Select All That Apply