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Chapter 29: Critical Care of Patients With
Respiratory Emergencies Ignatavicius:
Medical-Surgical Nursing, 10th Edition
Verified and Updated Questions and
Answers (100% Correct Answers)
1. A nurse answers a call light and finds a client anxious, short of breath, reporting
chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes
priority?
a. Assess the client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.
Answer: ANS: B
This client has signs and symptoms of a pulmonary embolism, and the most critical
action is to notify the Rapid Response Team for speedy diagnosis and treatment. The
other actions are appropriate also but are not the priority.
2. 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. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found.
Answer: ANS: C
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting
events, including PE. A client with no known risk factors for this disorder would be
asked about family history and referred for testing. Encouraging the client to walk is
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healthy, but is not related to the development of a PE in this case, nor is smoking.
Although there are cases of disease where no cause is ever found, this assumption is
premature.
3. A client has a large pulmonary embolism and is started on oxygen. The nurse asks
the charge nurse why the client's oxygen saturation 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."
Answer: ANS: C
A large blood clot in the lungs will significantly impair gas exchange and
oxygenation. Unless the clot is dissolved, this process will continue unabated.
Hyperventilation can interfere with oxygenation by shallow breathing, but there is no
evidence that the client is hyperventilating, and this is also not the most precise
physiologic answer. Acute respiratory distress syndrome can occur, but this is not as
likely soon after the client starts on oxygen plus there is no indication of how much
oxygen the client is on. The client may need to be mechanically ventilated, but
without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
4. A client is on intravenous heparin to treat a pulmonary embolism. The client's
most recent partial thromboplastin time (PTT) was 25 seconds. What order would 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.
Answer: ANS: B
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to
demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this
client's PTT value is too low. The heparin rate needs to be increased. Warfarin is not
indicated in this situation.
Chapter 29: Critical Care of Patients With
Respiratory Emergencies Ignatavicius:
Medical-Surgical Nursing, 10th Edition
Verified and Updated Questions and
Answers (100% Correct Answers)
1. A nurse answers a call light and finds a client anxious, short of breath, reporting
chest pain, and has a blood pressure of 88/52 mm Hg. What action by the nurse takes
priority?
a. Assess the client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.
Answer: ANS: B
This client has signs and symptoms of a pulmonary embolism, and the most critical
action is to notify the Rapid Response Team for speedy diagnosis and treatment. The
other actions are appropriate also but are not the priority.
2. 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. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found.
Answer: ANS: C
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting
events, including PE. A client with no known risk factors for this disorder would be
asked about family history and referred for testing. Encouraging the client to walk is
, Inquire through: | Professional | Confidential Support
healthy, but is not related to the development of a PE in this case, nor is smoking.
Although there are cases of disease where no cause is ever found, this assumption is
premature.
3. A client has a large pulmonary embolism and is started on oxygen. The nurse asks
the charge nurse why the client's oxygen saturation 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."
Answer: ANS: C
A large blood clot in the lungs will significantly impair gas exchange and
oxygenation. Unless the clot is dissolved, this process will continue unabated.
Hyperventilation can interfere with oxygenation by shallow breathing, but there is no
evidence that the client is hyperventilating, and this is also not the most precise
physiologic answer. Acute respiratory distress syndrome can occur, but this is not as
likely soon after the client starts on oxygen plus there is no indication of how much
oxygen the client is on. The client may need to be mechanically ventilated, but
without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.
4. A client is on intravenous heparin to treat a pulmonary embolism. The client's
most recent partial thromboplastin time (PTT) was 25 seconds. What order would 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.
Answer: ANS: B
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to
demonstrate that the heparin is working. A normal PTT is 25 to 35 seconds, so this
client's PTT value is too low. The heparin rate needs to be increased. Warfarin is not
indicated in this situation.
