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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?
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. b
This client has manifestations 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.
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
NURS 2765 A NURSING EXAM QUESTIONS
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c. Red blood cell count: 4.8/mm3
d. White blood cell count: 8.7/mm3 b
This platelet count is low and could indicate heparin-induced
thrombocytopenia. The other values are normal for either gender.
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 supply.
d. Tell the client to take slow, deep breaths. a
Pulse oximetry is not always the most accurate assessment tool
for hypoxia as many factors can interfere, producing normal or
NURS 2765 A NURSING EXAM QUESTIONS
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,NURS 2765 A NURSING EXAM QUESTIONS
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near-normal readings in the setting of hypoxia. The nurse should
conduct a more thorough assessment. The other actions are not
appropriate for a hypoxic client.
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.
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 should be referred for testing.
Encouraging the client to walk is 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.
A client has a pulmonary embolism and is started on oxygen. The
student nurse asks why the client's oxygen saturation has not
NURS 2765 A NURSING EXAM QUESTIONS
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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." 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. Respiratory distress syndrome can
occur, but this is not as likely. The client may need to be
mechanically ventilated, but without concrete data on FiO2 and
SaO2, the nurse cannot make that judgment.
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 should the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
NURS 2765 A NURSING EXAM QUESTIONS
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