NURS QUESTIONS WITH ANSWERS WEEK 9
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?
• Decrease the heparin rate.
• Increase the heparin rate.
• No change to the heparin rate.
• Stop
heparin; start
warfarin
(Coumadin).
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?
• Instruct the client to eliminate all vitamin K
from the diet.
• Prepare preoperative teaching for an inferior
vena cava (IVC) filter.
• Refer the client to a chronic illness support
group.
• Teach the
client to use a
soft-bristled
toothbrush.
Often clients are discharged from the hospital on
warfarin (Coumadin) after a PE. However, clients
with a variation in the CYP2C19 gene do not
metabolize warfarin well and have higher blood
levels and more side effects. This client is a poor
candidate for warfarin therapy, and the prescriber
will most likely order an IVC filter device to be
implanted. The nurse should prepare to do
preoperative teaching on this procedure. It would
be impossible to eliminate all vitamin K from the
diet. A chronic illness support group may be
needed, but this is not the best intervention as it
is not as specific to the client as the IVC filter. A
soft-bristled toothbrush is a safety measure for
clients on anticoagulation therapy.
A nurse is caring for four clients on intravenous
heparin therapy. Which laboratory value possibly
indicates that a serious side effect has occurred?
• Hemoglobin: 14.2 g/dL
• Platelet count: 82,000/L
,• Red blood cell count: 4.8/mm3
• White
blood cell
count:
8.7/mm3
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?
• Assess for other manifestations of hypoxia.
• Change the sensor on the pulse oximeter.
• Obtain a new oximeter from the central supply.
• Tell the
client to take
slow, deep
breaths
Pulse oximetry is not always the most accurate
assessment tool for hypoxia as many factors can
interfere, producing normal or
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 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?
• Ensure the client has adequate sedation.
• Find another provider to intubate.
• Interrupt the procedure to give oxygen.
• Monitor
the client's
oxygen
saturation
Each intubation attempt should not exceed 30
seconds (15 is preferable) as it causes hypoxia.
The nurse should interrupt the intubation attempt
and give the client oxygen. The nurse should also
have adequate sedation during the procedure
and monitor the client's oxygen saturation, but
these do not take priority. Finding another
provider is not appropriate at this time.
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse
, takes priority?
• Determine if the tube is kinked.
• Ensure all connections are patent.
• Listen to the client's lung sounds.
• Suction
the
endotrache
al tube
When an intubated client shows signs of hypoxia,
check for DOPE: displaced tube (most common
cause), obstruction (often by secretions),
pneumothorax, and equipment problems. The
nurse listens for equal, bilateral breath sounds
first to determine if the endotracheal tube is still
correctly placed. If this assessment is normal, the
nurse would follow the mnemonic and assess the
patency of the tube and connections and perform
suction.
A client is on a ventilator and is sedated. What care may the nurse delegate to the
unlicensed assistive personnel (UAP)?
• Assess the client for sedation needs.
• Get family permission for restraints.
• Provide frequent oral care per protocol.
• Use
nonverbal
pain
assessment
tools
The client on mechanical ventilation needs
frequent oral care, which can be delegated to the
UAP. The other actions fall within the scope of
practice of the nurse.
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 is a priority?
• The client initiates spontaneous breaths.
• The inspired oxygen has adequate
humidification.
• The upper peak airway pressure limit alarm is
off.
• The upper peak
airway pressure
limit alarm is on.
The upper peak airway pressure limit alarm will
sound when the airway pressure reaches a preset
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?
• Decrease the heparin rate.
• Increase the heparin rate.
• No change to the heparin rate.
• Stop
heparin; start
warfarin
(Coumadin).
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?
• Instruct the client to eliminate all vitamin K
from the diet.
• Prepare preoperative teaching for an inferior
vena cava (IVC) filter.
• Refer the client to a chronic illness support
group.
• Teach the
client to use a
soft-bristled
toothbrush.
Often clients are discharged from the hospital on
warfarin (Coumadin) after a PE. However, clients
with a variation in the CYP2C19 gene do not
metabolize warfarin well and have higher blood
levels and more side effects. This client is a poor
candidate for warfarin therapy, and the prescriber
will most likely order an IVC filter device to be
implanted. The nurse should prepare to do
preoperative teaching on this procedure. It would
be impossible to eliminate all vitamin K from the
diet. A chronic illness support group may be
needed, but this is not the best intervention as it
is not as specific to the client as the IVC filter. A
soft-bristled toothbrush is a safety measure for
clients on anticoagulation therapy.
A nurse is caring for four clients on intravenous
heparin therapy. Which laboratory value possibly
indicates that a serious side effect has occurred?
• Hemoglobin: 14.2 g/dL
• Platelet count: 82,000/L
,• Red blood cell count: 4.8/mm3
• White
blood cell
count:
8.7/mm3
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?
• Assess for other manifestations of hypoxia.
• Change the sensor on the pulse oximeter.
• Obtain a new oximeter from the central supply.
• Tell the
client to take
slow, deep
breaths
Pulse oximetry is not always the most accurate
assessment tool for hypoxia as many factors can
interfere, producing normal or
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 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?
• Ensure the client has adequate sedation.
• Find another provider to intubate.
• Interrupt the procedure to give oxygen.
• Monitor
the client's
oxygen
saturation
Each intubation attempt should not exceed 30
seconds (15 is preferable) as it causes hypoxia.
The nurse should interrupt the intubation attempt
and give the client oxygen. The nurse should also
have adequate sedation during the procedure
and monitor the client's oxygen saturation, but
these do not take priority. Finding another
provider is not appropriate at this time.
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse
, takes priority?
• Determine if the tube is kinked.
• Ensure all connections are patent.
• Listen to the client's lung sounds.
• Suction
the
endotrache
al tube
When an intubated client shows signs of hypoxia,
check for DOPE: displaced tube (most common
cause), obstruction (often by secretions),
pneumothorax, and equipment problems. The
nurse listens for equal, bilateral breath sounds
first to determine if the endotracheal tube is still
correctly placed. If this assessment is normal, the
nurse would follow the mnemonic and assess the
patency of the tube and connections and perform
suction.
A client is on a ventilator and is sedated. What care may the nurse delegate to the
unlicensed assistive personnel (UAP)?
• Assess the client for sedation needs.
• Get family permission for restraints.
• Provide frequent oral care per protocol.
• Use
nonverbal
pain
assessment
tools
The client on mechanical ventilation needs
frequent oral care, which can be delegated to the
UAP. The other actions fall within the scope of
practice of the nurse.
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 is a priority?
• The client initiates spontaneous breaths.
• The inspired oxygen has adequate
humidification.
• The upper peak airway pressure limit alarm is
off.
• The upper peak
airway pressure
limit alarm is on.
The upper peak airway pressure limit alarm will
sound when the airway pressure reaches a preset
