rated A+ 2025/2026 updated
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart
rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the
client requires - ANS ✔✔preoxygenation prior to suctioning
After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP)
monitor indicates low pressures. Which action should the nurse take? - ANS ✔✔Increase the IV
fluid infusion per protocol
A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a
client who has acute respiratory distress syndrome (ARDS). Which of the following statements
by the newly licensed nurse indicates understanding of the teaching? - ANS ✔✔This medication
is given to facilitate ventilation
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse when
sexual intercourse can be resumed. Which response by the nurse is best? - ANS ✔✔Sexual
activity uses about as much energy as climbing two flights of stairs
A nurse is caring for a client who came to the ED reporting chest pain. The provider suspects a
myocardial infarction. While waiting for the troponin levels report, the client asks what this
blood test will show. Which of the following explanations should the nurse provide the client? -
ANS ✔✔Troponin is a heart muscle protein that appears in the bloodstream when there is
damage to the heart
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the
following actions should the nurse take to determine if the client is experiencing a myocardial
infarction? - ANS ✔✔Perform a 12-lead ECG
, The nurse assesses a client with dyspnea, decreased breath sounds, tracheal deviation, and
pulse oximetry reading of 86%. What is the nurse's interpretation of these findings? - ANS
✔✔Tension pneumothorax
What action by a new intensive care unit staff nurse would indicate that the nurse educator's
teaching about arterial pressure monitoring has been effective? - ANS ✔✔Positions the zero-
reference stopcock line level with the phlebostatic axis
A nurse is caring for a client who is receiving heparin by continuous IV fusion. Which of the
following meds should the nurse plan to administer in the event of an overdose? - ANS
✔✔Protamine sulfate
Which finding by the nurse caring for a patient with a right radial arterial line indicates a need
for the nurse to take immediate action? - ANS ✔✔The right hand feels cooler than the left hand
Which statement by the nurse when explaining the purpose of positive end expiratory pressure
(PEEP) to the patient's caregiver is accurate? - ANS ✔✔PEEP prevents the lung air sacs from
collapsing during exhalation
A nurse is planning the discharge of the client who has sleep apnea and requires bi-level
positive airway pressure (BIPAP) at night. The nurse should plan to consult with which of the
following health care team members to help educate the client? - ANS ✔✔Respiratory therapist
A nurse is caring for a 76 yr old client who has a recently placed central venous catheter and
reports hearing a gurgling sound on the side of the catheter insertion. Which of the following
complications should the nurse suspect? - ANS ✔✔Catheter migration
The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment
depression and T-wave inversion. What should the nurse know that this indicates? - ANS
✔✔Myocardial ischemia