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? Notify the Rapid Response Team.
A client is admitted with a pulmonary embolism (PE). The clien...
NUR 114 Example Questions and Correct
Answers
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? ✅Notify the Rapid Response Team.
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? ✅Teach the client about factor V Leiden testing.
A client has a pulmonary embolism and is started on oxygen. The student nurse asks
why the clients oxygen saturation has not significantly improved. What response by the
nurse is best? ✅The blood clot interferes with perfusion in the lungs.
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? ✅Increase the heparin rate.
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? ✅Prepare preoperative teaching for an inferior vena cava (IVC)
filter.
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value
possibly indicates that a serious side effect has occurred? ✅Platelet count: 82,000/L
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse
is best? ✅Assess for other manifestations of hypoxia.
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?
✅Interrupt the procedure to give oxygen.
An intubated clients oxygen saturation has dropped to 88%. What action by the nurse
takes priority? ✅Listen to the clients lung sounds.
A client is on a ventilator and is sedated. What care may the nurse delegate to the
unlicensed assistive personnel (UAP)? ✅Provide frequent oral care per protocol.
, 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? ✅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? ✅Assess the cause of
the agitation.
A nurse is preparing to admit a client on mechanical ventilation from the emergency
department. What action by the nurse takes priority? ✅Ensuring there is a bag-valve-
mask in the room
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? ✅It will prevent ulcers from the stress of mechanical ventilation.
A client has been brought to the emergency department with a life-threatening chest
injury. What action by the nurse takes priority? ✅Ensure a patent airway.
A client is being discharged soon on warfarin (Coumadin). What menu selection for
dinner indicates the client needs more education regarding this medication? ✅Large
chefs salad and muffin
A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the
nurse indicates a possible barrier to self-management? ✅Strict vegetarian
A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action
by the student requires immediate intervention by the supervising nurse? ✅Choosing
an 18-gauge, 2-inch needle
A client in the emergency department has several broken ribs. What care measure will
best promote comfort? ✅Allowing the client to choose the position in bed
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? ✅Alteplase (Activase)
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? ✅Prepare to assist with intubation.
A student nurse asks for an explanation of refractory hypoxemia. What answer by the
nurse instructor is best? ✅It is hypoxemia that persists even with 100% oxygen
administration.
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