1. The nurse caring for a client who is receiving a heparin infusion for tx
of a PE. Which of the following indicates therapeutic effect on tx?
a. aPTT is 72 sec
b. Platelet count is 160,000
c. PT is 10.2 sec
d. D-dimer is increased at 600ng/mL
2. The nurse is caring for a client who is 4 days post-op and suddenly
develops difÏculty breathing and sharp CP. The nurse has called a rapid
response team, raised the head of the bed, and applied O2 to the
client. Which action from the box below should the nurse take next?
a. 1, 2, 4, 6
b. 1, 4, 5
c. 3, 4, 6
d. 2, 3, 5, 6
i. Auscultate the client’s lung sounds
ii. Initiate continuous cardiac monitoring
iii. Prepare to administer IV alteplase
iv. Connect the client to continuous pulse oximeter
v. Apply bilateral antiembolism stocking to the legs
vi. Assess the clients skin color
3. The nurse has provided discharge teaching to a client who developed a
PE following a surgical procedure. The client will be taking newly
prescribed warfarin at home. Which of the following client statements
indicates a correct understanding of the teaching?
a. “I will take this medication for the 1-2 months”
b. Hard candy can be used if develop a dry mouth while taking
warfarin
c. The warfarin will continue to break up the clot over the next
several months
d. I should avoid anything rectally, such as enemas or suppositories
4. The nurse is caring for a client who appears to have developed a PE.
Which of the following arterial blood gas ABG results would the nurse
expect the client to initially have?
a. pH 7. 45, PaO2 70mm, PaCO2 38, HCO3 28
b. pH 7. 35, PaO2 63mm, PaCO2 42, HCO3 26
c. pH 7. 31, PaO2 73mm, PaCO2 50, HCO3 22
d. pH 7. 50, PaO2 79mm, PaCO2 32, HCO3 23
5. The nurse is working in the emergency department caring for a client
who was in a boating crash 3 hours ago and has the following:
a. PE
b. Pleural effusion
c. A tension pneumothorax
d. Acute respiratory failure
i. Reports of headache
ii. Restless and irritable
iii. ABG: Respiratory acidosis
, iv. Pulse 110
v. RR 10 & dyspneic
vi. BP 145/86
6. The nurse is caring for a client who has a chest tube. Which
assessment findings from below requires immediate action to tell the
provider?
a. 1, 3, 6
b. 1, 2, 3, 4
c. 2, 3, 6
d. 2, 4, 5
i. Continuous bubbling in the suction control chamber
ii. Idk,
iii. Tidaling in the water chamber with breathing
iv. 100mL of drainage within an hour
v. Visibility of eyelids of the chest tube
vi. Low water level in the water seal chamber
7. The nurse is assessing a client who had a chest tube 36 hours ago for
the tx of a pneumothorax. The nurse observes continuous bubbling in
the water seal chamber. Which of the following action should the nurse
take?
a. Document that the chest tube system is operating properly
b. Inform the PHCP that there is a leak in the system
c. Turn off the suction, assist the lung sounds, and turn the suction
back on
d. Ensure the drainage system is off the floor and hanging on the
bed frame
8. The nurse is assessing clients for the risk of developing ARDS. The
nurse should identify at greatest risk the client who
a. Had a stroke and is having difÏculty swallowing
b. Has thyroid cancer and is receiving outpatient radiation therapy
c. Had a MI and is receiving therapy
d. Had an outpatient lap cholecystectomy and is taking prescribed
opioid analgesics
9. The nurse has been made aware of the following client situations. The
nurse should initially follow up with client who is receiving:
a. mechanical ventilation for the treatment of ARDS and has an
absence of breath sounds in the left lower lobe
b. oxygen at 4 liters nasal cannula has bilateral lower lobe
pneumonia has not used the incentive spirometer in six hours
c. a continuous infusion of heparin sodium at 1500 units/hr for the
treatment of PE and has a PTT of 60 seconds
d. mechanical ventilation for the treatment of a hospital acquired
pneumonia and was last suctioned via the endotracheal tube two
hours ago
of a PE. Which of the following indicates therapeutic effect on tx?
a. aPTT is 72 sec
b. Platelet count is 160,000
c. PT is 10.2 sec
d. D-dimer is increased at 600ng/mL
2. The nurse is caring for a client who is 4 days post-op and suddenly
develops difÏculty breathing and sharp CP. The nurse has called a rapid
response team, raised the head of the bed, and applied O2 to the
client. Which action from the box below should the nurse take next?
a. 1, 2, 4, 6
b. 1, 4, 5
c. 3, 4, 6
d. 2, 3, 5, 6
i. Auscultate the client’s lung sounds
ii. Initiate continuous cardiac monitoring
iii. Prepare to administer IV alteplase
iv. Connect the client to continuous pulse oximeter
v. Apply bilateral antiembolism stocking to the legs
vi. Assess the clients skin color
3. The nurse has provided discharge teaching to a client who developed a
PE following a surgical procedure. The client will be taking newly
prescribed warfarin at home. Which of the following client statements
indicates a correct understanding of the teaching?
a. “I will take this medication for the 1-2 months”
b. Hard candy can be used if develop a dry mouth while taking
warfarin
c. The warfarin will continue to break up the clot over the next
several months
d. I should avoid anything rectally, such as enemas or suppositories
4. The nurse is caring for a client who appears to have developed a PE.
Which of the following arterial blood gas ABG results would the nurse
expect the client to initially have?
a. pH 7. 45, PaO2 70mm, PaCO2 38, HCO3 28
b. pH 7. 35, PaO2 63mm, PaCO2 42, HCO3 26
c. pH 7. 31, PaO2 73mm, PaCO2 50, HCO3 22
d. pH 7. 50, PaO2 79mm, PaCO2 32, HCO3 23
5. The nurse is working in the emergency department caring for a client
who was in a boating crash 3 hours ago and has the following:
a. PE
b. Pleural effusion
c. A tension pneumothorax
d. Acute respiratory failure
i. Reports of headache
ii. Restless and irritable
iii. ABG: Respiratory acidosis
, iv. Pulse 110
v. RR 10 & dyspneic
vi. BP 145/86
6. The nurse is caring for a client who has a chest tube. Which
assessment findings from below requires immediate action to tell the
provider?
a. 1, 3, 6
b. 1, 2, 3, 4
c. 2, 3, 6
d. 2, 4, 5
i. Continuous bubbling in the suction control chamber
ii. Idk,
iii. Tidaling in the water chamber with breathing
iv. 100mL of drainage within an hour
v. Visibility of eyelids of the chest tube
vi. Low water level in the water seal chamber
7. The nurse is assessing a client who had a chest tube 36 hours ago for
the tx of a pneumothorax. The nurse observes continuous bubbling in
the water seal chamber. Which of the following action should the nurse
take?
a. Document that the chest tube system is operating properly
b. Inform the PHCP that there is a leak in the system
c. Turn off the suction, assist the lung sounds, and turn the suction
back on
d. Ensure the drainage system is off the floor and hanging on the
bed frame
8. The nurse is assessing clients for the risk of developing ARDS. The
nurse should identify at greatest risk the client who
a. Had a stroke and is having difÏculty swallowing
b. Has thyroid cancer and is receiving outpatient radiation therapy
c. Had a MI and is receiving therapy
d. Had an outpatient lap cholecystectomy and is taking prescribed
opioid analgesics
9. The nurse has been made aware of the following client situations. The
nurse should initially follow up with client who is receiving:
a. mechanical ventilation for the treatment of ARDS and has an
absence of breath sounds in the left lower lobe
b. oxygen at 4 liters nasal cannula has bilateral lower lobe
pneumonia has not used the incentive spirometer in six hours
c. a continuous infusion of heparin sodium at 1500 units/hr for the
treatment of PE and has a PTT of 60 seconds
d. mechanical ventilation for the treatment of a hospital acquired
pneumonia and was last suctioned via the endotracheal tube two
hours ago
