A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a
blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority?B
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no
known risk factors for PE. What action by the nurse is most appropriate?
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the clients oxygensaturation has not significantly improved. What response by the nurse is best?
a. Breathing so rapidly interferes with oxygenation.
b. Maybe the client has respiratory distress syndrome.
c. The blood clot interferes with perfusion in the lungs
d. The client needs immediate intubation and mechanical ventilation
A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent partial
thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin
A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals
the client has an alteration in the gene CYP2C19. What action by the nurse is best?
a. Instruct the client to eliminate all vitamin K from the diet.
b. Prepare preoperative teaching for an inferior vena cava (IVC)
c. Refer the client to a chronic illness support group.
d. Teach the client to use a soft-bristled toothbrush
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates
that a serious side effect has occurred?
a. Hemoglobin: 14.2 g/dL
b. Platelet count: 82,000/L
c. Red blood cell count: 4.8/mm3
d. White blood cell count:
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central
d. Tell the client to take slow, deep breaths
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to
intubate for 40 seconds. What action by the nurse takes priority?
a. Ensure the client has adequate sedation.
b. Find another provider to intubate.
c. Interrupt the procedure to give oxygen.
d. Monitor the clients oxygen saturation.
An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes priority?
a. Determine if the tube is kinked.
b. Ensure all connections are patent.
c. Listen to the clients lung sounds.
d. Suction the endotracheal tube.
A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive
a. Assess the client for sedation needs.
b. Get family permission for restraints.
c. Provide frequent oral care per
d. Use nonverbal pain assessment tools.C
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with
the respiratory therapist, what should the nurse ensure as a priority?
a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate
c. The upper peak airway pressure limit alarm is
d. The upper peak airway pressure limit alarm is on.
A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about.
What action by the nurse is most appropriate?
a. Assess the cause of the agitation.
b. Reassure the client that he or she is
c. Restrain the clients hands.
d. Sedate the client immediately
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What
action by the nurse takes priority?
a. Assessing that the ventilator settings are correct
b. Ensuring there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
d. Planning to suction the client upon arrival to the
A client is on mechanical ventilation and the clients spouse wonders why ranitidine (Zantac) is needed since
the client only has lung problems. What response by the nurse is best?
a. It will increase the motility of the gastrointestinal tract.
b. It will keep the gastrointestinal tract functioning normally.
c. It will prepare the gastrointestinal tract for enteral feedings.
d. It will prevent ulcers from the stress of mechanical
A client has been brought to the emergency department with a life-threatening chest injury. What action by
the nurse takes priority?
a. Apply oxygen at 100%.
b. Assess the respiratory rate.
c. Ensure a patent airway.
d. Start two large-bore IV
client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the
client needs more education regarding this medication?
a. Hamburger and French fries
b. Large chefs salad and muffin
c. No selection; spouse brings
d. Tuna salad sandwich and chips
nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a
possible barrier to self-management?
a. Poor visual acuity
b. Strict vegetarian
c. Refusal to stop smoking
d. Wants weight loss
A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student
requires immediate intervention by the supervising nurse?
a. Assessing the clients platelet count
b. Choosing an 18-gauge, 2-inch needle
c. Not aspirating prior to injection
d. Swabbing the injection site with
A client in the emergency department has several broken ribs. What care measure will best promote
a. Allowing the client to choose the position in bed
b. Humidifying the supplemental oxygen
c. Offering frequent, small drinks of water
d. Providing warmed blankets
A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure.
What medication should the nurse anticipate the client will need as the priority?
a. Alteplase (Activase)
b. Enoxaparin (Lovenox)
c. Unfractionated heparin
d. Warfarin sodium
A client is brought to the emergency department after sustaining injuries in a severe car crash. The clients
chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is
cyanotic. What action by the nurse is the priority?
a. Administer oxygen and reassess.
b. Auscultate the clients lung
c. Facilitate a portable chest x-ray.
d. Prepare to assist with intubation.
student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is
a. It is chronic hypoxemia that accompanies restrictive airway disease.
b. It is hypoxemia from lung damage due to mechanical ventilation.
c. It is hypoxemia that continues even after the client is weaned from
d. It is hypoxemia that persists even with 100% oxygen administration
A nurse is caring for a client on the medical stepdown unit. The following data are related to this client:
Subjective Information Laboratory Analysis Physical Assessment
Shortness of breath for 20
Cant catch my breath
PaCO2: 28 mm Hg
PaO2: 58 mm Hg
Pulse: 120 beats/min
Respiratory rate: 34
Blood pressure 158/92 mm Hg
Lungs have crackles
What action by the nurse is most appropriate?
a. Call respiratory therapy for a breathing
b. Facilitate a STAT pulmonary angiography.
c. Prepare for immediate endotracheal intubation.
d. Prepare to administer intravenous anticoagulants.
A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a
pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
c. Middle-aged man with an exacerbation of asthma
d. Older client who is 1-day post hip replacement
e. Young obese client with a fractured femur
When working with women who are taking hormonal birth control, what health promotion measures should
the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
a. Avoid drinking alcohol.
b. Eat more omega-3 fatty
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes.
A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate?
(Select all that apply.)
a. Acknowledge the frightening nature of the illness.
b. Delegate a back rub to the unlicensed assistive personnel
c. Give simple explanations of what is happening.
d. Request a prescription for antianxiety medication.
e. Stay with the client and speak in a quiet, calm voice
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
a. Adherence to proper hand hygiene
b. Administering anti-ulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
e. Suctioning the client on a regular
A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this
client? (Select all that apply.)
a. Allow visitors at the clients bedside.
b. Ensure the client can communicate if awake.
c. Keep the television tuned to a favorite channel.
d. Provide back and hand massages when
e. Turn the client every 2 hours or more.
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning
failure. What age-related changes contribute to this? (Select all that apply.)
a. Chest wall stiffness
b. Decreased muscle
c. Inability to cooperate
d. Less lung elasticity
e. Poor vision and hearing
A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse
anticipate for tidal volume? (Record your answer using a whole number.) ___ mL