Unit 4 PE/chest trauma/acute respiratory
distress (ARD) (test book) NCLEX
Answered
The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis?
1. Plasma D-dimer test.
2. Arterial blood gases.
3. Chest x-ray.
4. Magnetic resonance imaging.
---1. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer
indicates a thrombus formation and lysis.
2. An ABG evaluates oxygenation level, but it does not diagnose a pulmonary embolus (PE).
3. A CXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE.
4. An MRI is a noninvasive test that detects a deep vein thrombosis, but it does not diagnose a
pulmonary embolus.
Which nursing assessment data support that the client has experienced a pulmonary embolism?
1. Calf pain with dorsiflexion of the foot.
2. Sudden onset of chest pain and dyspnea.
3. Left-sided chest pain and diaphoresis.
4. Bilateral crackles and low-grade fever.
1. This is a sign of a deep vein thrombosis, which is a precursor to a pulmonary embolism, but it is not a
sign of a pulmonary embolism.
---2. The most common signs of a pulmonary embolism are sudden onset of chest pain when taking a
deep breath and shortness of breath.
3. These are signs of a myocardial infarction.
4. These could be signs of pneumonia or other pulmonary complications, but not specifically a
pulmonary embolism.
The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data
warrant immediate intervention from the nurse?
,1. The client's ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24.
2. The client's telemetry exhibits occasional premature ventricular contractions.
3. The client's pulse oximeter reading is 90%.
4. The client's urinary output for the 12-hour shift is 800 mL.
1. The ABGs are within normal limits and would not warrant immediate intervention.
2. Occasional premature ventricular contractions are not unusual for any client and would not warrant
immediate intervention.
---3. The normal pulse oximeter reading is 93% to 100%. A reading of 90% indicates the client has an
arterial oxygen level of around 60.
4. A urinary output of 800 mL over 12 hours indicates an output of greater than 30 mL/hour and would
not warrant immediate intervention by the nurse.
The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention
should the nurse implement?
1. Administer oral anticoagulants.
2. Assess the client's bowel sounds.
3. Prepare the client for a thoracentesis.
4. Institute and maintain bedrest.
1. The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not
oral anticoagulants.
2. The client's respiratory system will be assessed, not the gastrointestinal system.
3. A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE.
---4. Bedrest reduces the risk of another clot becoming an embolus leading to a pulmonary embolus.
Bedrest reduces metabolic demands and tissue needs for oxygen in the lungs.
The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a
PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement?
1. Assess the client for abnormal bleeding.
2. Prepare to administer vitamin K (AquaMephyton).
3. Administer the medication as ordered.
4. Notify the HCP to obtain an order to increase the dose.
1. The client would not be experiencing abnormal bleeding with this INR.
2. This is the antidote for an overdose of anticoagulant and the INR does not indicate this.
, ---3. A therapeutic INR is 2 to 3; therefore, the nurse should administer the medication.
4. There is no need to increase the dose; this result is within the therapeutic range.
The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a
pulmonary embolus. Which intervention should be included in the plan of care?
1. Monitor the client's arterial blood gases.
2. Assess skin color and temperature.
3. Check the client for signs of bleeding.
4. Keep the client in the Trendelenburg position.
1. Arterial blood gases would be included in the client problem "impaired gas exchange."
--2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output.
3. This would be appropriate for the client problem "high risk for bleeding."
4. The client should not be put in a position with the head lower than the legs because this would
increase difficulty breathing.
Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary
embolus who is undergoing thrombolytic therapy? Select all that
apply.
1. Keep protamine sulfate readily available.
2. Avoid applying pressure to venipuncture sites.
3. Assess for overt and covert signs of bleeding.
4. Avoid invasive procedures and injections.
5. Administer stool softeners as ordered.
---1. Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and
should be available to reverse the effects of the anticoagulant.
2. Firm pressure reduces the risk for bleeding into the tissues.
---3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for.
---4. Invasive procedures increase the risk of tissue trauma and bleeding.
---5. Stool softeners help prevent constipation and straining, which may precipitate bleeding from
hemorrhoids.
Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching
is effective?
1. "I am going to use a regular-bristle toothbrush."
distress (ARD) (test book) NCLEX
Answered
The client is suspected of having a pulmonary embolus. Which diagnostic test confirms the diagnosis?
1. Plasma D-dimer test.
2. Arterial blood gases.
3. Chest x-ray.
4. Magnetic resonance imaging.
---1. The plasma D-dimer test is highly specific for the presence of a thrombus; an elevated D-dimer
indicates a thrombus formation and lysis.
2. An ABG evaluates oxygenation level, but it does not diagnose a pulmonary embolus (PE).
3. A CXR shows pulmonary infiltration and pleural effusions, but it does not diagnose a PE.
4. An MRI is a noninvasive test that detects a deep vein thrombosis, but it does not diagnose a
pulmonary embolus.
Which nursing assessment data support that the client has experienced a pulmonary embolism?
1. Calf pain with dorsiflexion of the foot.
2. Sudden onset of chest pain and dyspnea.
3. Left-sided chest pain and diaphoresis.
4. Bilateral crackles and low-grade fever.
1. This is a sign of a deep vein thrombosis, which is a precursor to a pulmonary embolism, but it is not a
sign of a pulmonary embolism.
---2. The most common signs of a pulmonary embolism are sudden onset of chest pain when taking a
deep breath and shortness of breath.
3. These are signs of a myocardial infarction.
4. These could be signs of pneumonia or other pulmonary complications, but not specifically a
pulmonary embolism.
The client diagnosed with a pulmonary embolus is in the intensive care unit. Which assessment data
warrant immediate intervention from the nurse?
,1. The client's ABGs are pH 7.36, PaO2 95, PaCO2 38, HCO3 24.
2. The client's telemetry exhibits occasional premature ventricular contractions.
3. The client's pulse oximeter reading is 90%.
4. The client's urinary output for the 12-hour shift is 800 mL.
1. The ABGs are within normal limits and would not warrant immediate intervention.
2. Occasional premature ventricular contractions are not unusual for any client and would not warrant
immediate intervention.
---3. The normal pulse oximeter reading is 93% to 100%. A reading of 90% indicates the client has an
arterial oxygen level of around 60.
4. A urinary output of 800 mL over 12 hours indicates an output of greater than 30 mL/hour and would
not warrant immediate intervention by the nurse.
The client is admitted to the medical unit diagnosed with a pulmonary embolus. Which intervention
should the nurse implement?
1. Administer oral anticoagulants.
2. Assess the client's bowel sounds.
3. Prepare the client for a thoracentesis.
4. Institute and maintain bedrest.
1. The intravenous anticoagulant heparin will be administered immediately after diagnosis of a PE, not
oral anticoagulants.
2. The client's respiratory system will be assessed, not the gastrointestinal system.
3. A thoracentesis is used to aspirate fluid from the pleural space; it is not a treatment for a PE.
---4. Bedrest reduces the risk of another clot becoming an embolus leading to a pulmonary embolus.
Bedrest reduces metabolic demands and tissue needs for oxygen in the lungs.
The nurse is preparing to administer the oral anticoagulant warfarin (Coumadin) to a client who has a
PT/PTT of 22/39 and an INR of 2.8. What action should the nurse implement?
1. Assess the client for abnormal bleeding.
2. Prepare to administer vitamin K (AquaMephyton).
3. Administer the medication as ordered.
4. Notify the HCP to obtain an order to increase the dose.
1. The client would not be experiencing abnormal bleeding with this INR.
2. This is the antidote for an overdose of anticoagulant and the INR does not indicate this.
, ---3. A therapeutic INR is 2 to 3; therefore, the nurse should administer the medication.
4. There is no need to increase the dose; this result is within the therapeutic range.
The nurse identified the client problem "decreased cardiac output" for the client diagnosed with a
pulmonary embolus. Which intervention should be included in the plan of care?
1. Monitor the client's arterial blood gases.
2. Assess skin color and temperature.
3. Check the client for signs of bleeding.
4. Keep the client in the Trendelenburg position.
1. Arterial blood gases would be included in the client problem "impaired gas exchange."
--2. These assessment data monitor tissue perfusion, which evaluates for decreased cardiac output.
3. This would be appropriate for the client problem "high risk for bleeding."
4. The client should not be put in a position with the head lower than the legs because this would
increase difficulty breathing.
Which nursing interventions should the nurse implement for the client diagnosed with a pulmonary
embolus who is undergoing thrombolytic therapy? Select all that
apply.
1. Keep protamine sulfate readily available.
2. Avoid applying pressure to venipuncture sites.
3. Assess for overt and covert signs of bleeding.
4. Avoid invasive procedures and injections.
5. Administer stool softeners as ordered.
---1. Heparin is administered during thrombolytic therapy, and the antidote is protamine sulfate and
should be available to reverse the effects of the anticoagulant.
2. Firm pressure reduces the risk for bleeding into the tissues.
---3. Obvious (overt) as well as hidden (covert) signs of bleeding should be assessed for.
---4. Invasive procedures increase the risk of tissue trauma and bleeding.
---5. Stool softeners help prevent constipation and straining, which may precipitate bleeding from
hemorrhoids.
Which statement by the client diagnosed with a pulmonary embolus indicates the discharge teaching
is effective?
1. "I am going to use a regular-bristle toothbrush."
