front 1 1. Which patient requires immediate intervention by the nurse to
decrease the risk for developing a deep vein thrombosis (DVT)? | back 1 1. The patient who is immobile because of a fractured hip |
front 2 2. Which prescription is the most important to decrease the risk of
deep vein thrombus in a patient after surgery? | back 2 4. Ambulate every 2 to 4 hours |
front 3 3. A patient diagnosed with a pulmonary embolism has a reduction in
arterial oxygen saturation level and dyspnea. Which is the priority
nursing diagnosis for this patient? | back 3 3. Impaired Gas Exchange |
front 4 4. The patient is receiving heparin therapy for a deep vein
thrombosis. Which activated partial thromboplastin time (aPTT)
indicates to the nurse that anticoagulation is adequate? | back 4 1. The patient's aPPT is twice the control value. |
front 5 5. The nurse is planning care for a newly admitted patient diagnosed
with pulmonary embolism. In preparing to implement prescribed
anticoagulant therapy, it is important that the nurse recognize which
information regarding this therapy? | back 5 3. Heparin and warfarin (Coumadin) are usually initiated at the same time. |
front 6 6. The nurse provides care to a patient who is prescribed
thrombolytic therapy to treat a deep vein thrombosis (DVT). Which
patient information is an absolute contraindication to this therapy
necessitating the nurse to question the medication current
prescription? | back 6 4. Motor vehicle crash 1 month ago |
front 7 7. The nurse has instructed a patient recovering from a pulmonary
embolism on long-term | back 7 2. "I need to use a soft toothbrush and an electric razor and avoid injuries." |
front 8 8. In the patient with acute respiratory failure, the nurse
interprets which set of arterial blood gases as 2. pH 7.32, PaCO2 48 mm Hg, HCO3- 3. pH 7.37, PaCO2 42 mm Hg, HCO3- 4. pH 7.47, PaCO2 30 mm Hg, HCO3- | back 8 1. pH 7.30, PaCO2 55 mm Hg, HCO3- |
front 9 9. Which arterial blood gas (ABG) results does the nurse recognize as
most indicative of impending | back 9 4. PaCO2 48 mm Hg; PaO2 60 mm Hg |
front 10 10. The nurse monitors for which clinical manifestations in the
patient experiencing intermediate respiratory failure? | back 10 2. Lethargy |
front 11 11. In triaging patients in the emergency department, the nurse
prioritizes the patient with which clinical manifestations? | back 11 2. Cyanosis and decreased level of consciousness |
front 12 12. In the patient admitted with acute respiratory distress syndrome
(ARDS), the nurse identifies the nursing diagnosis Impaired Gas
Exchange related to which physiological change? | back 12 2. Increased capillary permeability |
front 13 13. A patient admitted with smoke inhalation injuries develops
clinical manifestations of acute respiratory distress syndrome (ARDS).
The nurse prepares to implement which healthcare provider
prescription? | back 13 1. Intubation and mechanical ventilation |
front 14 14. The nurse is providing care for a patient requiring mechanical
ventilation. When the nurse enters the room at the beginning of the
shift, the patient's monitor displays a heart rate of 64 and oxygen
saturation of 88%. Which nursing action is the priority? | back 14 3. Assessing the patient for airway obstruction |
front 15 15. Which assessment finding alerts the nurse to the possibility that
the intrathoracic pressure in a mechanically ventilated patient is too
high? | back 15 4. Decreased respiratory effort |
front 16 16. A patient's blood pressure drops from 120/76 to 90/60 as soon as
positive end-expiratory pressure (PEEP) is initiated for the treatment
of hypoxemia. What is the most likely cause of this decrease in blood
pressure? | back 16 1. Decreased cardiac output |
front 17 17. The nurse correlates which mechanical ventilator setting as
placing a patient at greatest risk for barotrauma? | back 17 3. PEEP 7 cm H2O |
front 18 18. The nurse caring for a patient admitted with septic shock is
aware of the need to assess for the development of acute respiratory
distress syndrome (ARDS). Which early clinical manifestation indicate
the development of ARDS? | back 18 3. Tachypnea |
front 19 19. What should the nurse conclude if constant bubbling is noted in
the water-seal chamber of a closed chest drainage system? | back 19 1. The system has an air leak. |
front 20 20. After insertion of a chest tube for a pneumothorax, a patient
becomes hypotensive with neck vein distention, tracheal shift, absent
breath sounds, and diaphoresis. The nurse suspects a tension
pneumothorax has occurred. The nurse assesses for what potential cause
of tension pneumothorax? | back 20 4. Kinked or obstructed tube |
front 21 21. A patient who had a segmental left lung resection for treatment
of a lung carcinoma returns from surgery with a left posterolateral
chest tube attached to a disposable water-seal chest drainage system.
Which signs would indicate that the drainage system is working
properly? | back 21 2. The fluid level in the water-seal chamber fluctuates. |
front 22 22. The nurse assumes care for a patient receiving a heparin infusion at 20 mL/hour. If 25,000 units are mixed in 500 mL of fluid, how many units of heparin is the patient receiving per hour? (Enter the number with no spaces or units of measurement.) | back 22 1,000 |
front 23 23. The patient is prescribed a heparin infusion at start at 2,000 units/hour. If 50,000 units are mixed in 250 mL, at what rate (mL/hour) does the nurse set the pump? (Enter the number with no spaces or units of measurement.) | back 23 10 |
front 24 The nurse is providing care for a patient with acute respiratory
distress syndrome (ARDS). The patient's PaO2 is 75 and the ventilator
is providing an FIO2 of 0.50. What is the calculated | back 24 150 |
front 25 25. The nurse monitors for which clinical manifestations in the
patient diagnosed with a pulmonary embolism (PE)? Select all that
apply. | back 25 1. Tachypnea 3. Shortness of breath 5. Accessory muscle use |
front 26 26. The nurse correlates which disorders as placing a patient at
increased risk of acute respiratory failure (ARF) secondary to
hypoventilation? Select all that apply. | back 26 2. High spinal cord injury 5. Opioid overdose |
front 27 27. The nurse correlates which assessment data to the patient
experiencing early respiratory distress? Select all that
apply. | back 27 1. Dyspnea |
front 28 28. The nurse educator prepares to speak to a group of nursing
students about insults to the lungs that may lead to the development
of acute respiratory distress syndrome (ARDS). The nurse includes
which as causes related to direct injury to the lungs? Select all that
apply. | back 28 1. Aspiration 4. Pulmonary embolus |
front 29 29. The nurse monitors for which clinical manifestations in the
exudative phase of acute respiratory distress syndrome (ARDS)? Select
all that apply. | back 29 3. Hypoxemia |
front 30 30. In providing care to a patient who is being treated with
mechanical ventilation for acute respiratory failure, the nurse
understands the patient is at risk of ventilator-induced lung injury
that includes which pathophysiological processes? Select all that
apply. | back 30 1. Alveolar rupture 4. Inflammatory-cell infiltrates |