Evolve Ch. 32 Questions

Which client has the highest risk for developing a pulmonary embolism (PE)? A. A 25-year-old woman who frequently flies to different countries B. A 67-year-old man who works on a farm C. A 45-year-old man admitted for a heart attack D. A 23-year-old woman with a bleeding disorder

A. A 25 year old woman who frequently flies to different countries

While assessing a client who has been receiving heparin intravenously for the past 3 days, the nurse notes the IV pump is set at twice the required setting. What orders does the nurse anticipate from the prescriber? Select all that apply. A. Activated partial thromboplastin time B. International normalized ratio C. Prothrombin time D. Vitamin K E. Protamine sulfate

A. Activated partial thromboplastin time E. Protamine Sulfate

The medical-surgical unit nurse should call the Rapid Response Team to assess which client? A. Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis B. Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain C. Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry of 94% Incorrect D. Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs

A. Client with a diagnosed pulmonary embolism who is receiving IV heparin and has bright-red hemoptysis

The nurse is assessing a client with possible pulmonary embolism (PE). For which symptoms should the nurse assess? (Select all that apply.) A. Dizziness and fainting B. Shortness of breath (SOB) worsening over the last 2 weeks C. Inspiratory chest pain D. Productive cough E. Pink, frothy sputum

A. Dizziness and fainting C. Inspiratory Chest pain

The nurse caring for a client who is intubated and receiving mechanical ventilation notes that her oxygen saturation is 89%, her heart rate is 120 beats/min, and she is increasingly agitated and restless. On auscultation, the nurse finds the lung sounds are diminished on one side. Which action does the nurse perform first? A. Notify the provider and prepare for re-intubation or repositioning the tube. B. Document the findings and request sedation from the provider. C. Call respiratory therapy to obtain a set of arterial blood gasses. D. Reposition the tube, and call radiology for a stat chest x-ray.

A. Notify the provider and prepare for reintubation or repositioning of the tube.

Which intervention will be most effective in reducing anxiety in a client with a pulmonary embolism (PE)? A. Remain with the client and provide oxygen in a calm manner. B. Have the client breathe into a brown paper bag using pursed lips. C. Offer the client a mild sedative. D. Allow a family member to remain in the room.

A. Remain with the client and provide oxygen in a calm manner.

The nurse is overseeing a nursing student who is administering medications to a group of clients with pulmonary disorders. Which statement by the student nurse indicates a correct understanding about thrombolytic therapy? A. "You will receive a dose of enoxaparin (Lovenox) intramuscularly for 3 days." B. "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3." C. "Once the health care provider orders warfarin (Coumadin), we will discontinue the intravenous heparin." D. "If bleeding develops, we will give you platelets to reverse the anticoagulant."

B. "Therapy with warfarin (Coumadin) is effective when your INR is between 2 and 3."

The nurse is caring for a client with impending respiratory failure who refuses intubation and mechanical ventilation. Which method provides an alternative to mechanical ventilation? A. Oropharyngeal airway B. Bi-level positive airway pressure (BiPAP) C. Non-rebreather mask with 100% oxygen D. Positive end-expiratory pressure (PEEP)

B. BiPAP

A client has been admitted for a pulmonary embolism and is receiving heparin infusion. What safety priority does the nurse include in the plan of care? A. Teach the client to avoid using dental floss. B. Monitor the platelet count daily. C. Ensure adequate staffing for the unit. D. Notify radiology of an impending scan.

B. Monitor the platelet count daily

The nurse is assessing a client who is receiving mechanical ventilation with positive end-expiratory pressure. Which findings would cause the nurse to suspect a left-sided tension pneumothorax? A. The chest caves in on inspiration and "puffs out" on expiration. Incorrect B. The trachea is deviated to the right side and cyanosis is present. C. The left lung field is dull to percussion with crackles present on auscultation. D. The client has bloody sputum and wheezes.

B. The trachea is deviated to the right side and cyanosis is present.

The client with which condition is in greatest need of immediate intubation? A. Difficulty swallowing oral secretions B. Hypoventilation and decreased breath sounds C. O2 saturation of 90% D. Thick, purulent secretions and crackles

B. hypoventilation and decreased breath sounds

When caring for a client with pulmonary embolism (PE), which arterial blood gas results does the nurse anticipate early in the course of the disease? A. pH 7.24, PaCO2 55 mm Hg, HCO3- 26 mEq/L, PaO2 56 mm Hg B. pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg C. pH 7.35, PaCO2 45 mm Hg, HCO3- 24 mEq/L, PaO2 80 mm Hg D. pH 7.47, PaCO2 35 mm Hg, HCO3- 30 mEq/L, PaO2 75 mm Hg

B. pH 7.46, PaCO2 30 mm Hg, HCO3- 26 mEq/L, PaO2 68 mm Hg

Which critically ill client has the greatest risk for developing acute respiratory distress syndrome (ARDS)? A. Client with diabetic ketoacidosis (DKA) B. Client with atrial fibrillation C. Client with aspiration pneumonia D. Client with acute kidney failure

C. Client w/ aspiration pneumonia

The nurse is developing a plan of care for a client with pulmonary embolism (PE). Which client problem does the nurse establish as the priority? A. Inadequate nutrition related to food-drug interactions and anticoagulant therapy B. Potential for infection related to leukocytosis C. Hypoxemia related to ventilation-perfusion mismatch D. Insufficient knowledge related to the cause of PE

C. Hypoxemia related to ventilation-perfusion mismatch

A student nurse is working with a client in the ICU who is intubated and being mechanically ventilated. What action by the student causes the registered nurse to intervene? A. Repositioning the client every 2 hours B. Providing oral care with chlorhexidine rinse C. Checking tube placement at the client's incisor D. Turning off ventilator alarms while working in the room

D. Turning off ventilator alarms while working in the room.

The nurse is caring for a client who was discharged 3 weeks ago after a diagnosis of pulmonary embolism (PE). He is currently admitted with gastrointestinal (GI) bleeding and an international normalized ratio (INR) of 6.9. For which factors should the nurse assess this client? A. Consumption of green leafy vegetables B. Prolonged exhalation C. Client has massaged his calves D. Use of aspirin or salicylates

D. Use of aspirin or salicylates

The nurse is caring for a group of clients. Which person does the nurse identify as having the highest risk for pulmonary embolism (PE)? A. A client with diabetes and cellulitis of the leg B. A client receiving IV fluids through a peripheral line C. A client returning from an open reduction and internal fixation of the tibia D. A client with hypokalemia receiving potassium supplements

c. A client returning from an open reduction and internal fixation of the tibia