A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.)
a. Acknowledge the frightening nature of the illness.
b. Delegate a back rub to the unlicensed assistive personnel (UAP).
c. Give simple explanations of what is happening.
d. Request a prescription for antianxiety medication.
e. Stay with the client and speak in a quiet, calm voice.
Question 2The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
a. Adherence to proper hand hygiene
b. Administering anti-ulcer medication
c. Elevating the head of the bed
d. Providing oral care per protocol
e. Suctioning the client on a regular schedule
Question 3A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed
c. Middle-aged man with an exacerbation of asthma
d. Older client who is 1-day post hip replacement surgery
e. Young obese client with a fractured femur
Question 4A nurse is caring for a client on the medical stepdown unit. The following data are related to this client:
Subjective Information
Laboratory Analysis
Physical Assessment
Shortness of breath for 20 minutes
Feels frightened
Can't catch my breath
pH: 7.12
PaCO2: 28 mm Hg
PaO2: 58 mm Hg
SaO2: 88
Pulse: 120 beats/min
Respiratory rate: 34 breaths/min
Blood pressure 158/92 mm Hg
Lungs have crackles
What action by the nurse is most appropriate?
a.
Call respiratory therapy for a breathing treatment.
b.
Facilitate a STAT pulmonary angiography.
c.
Prepare for immediate endotracheal intubation.
d.
Prepare to administer intravenous anticoagulants.
Question 5A student nurse asks for an explanation of refractory hypoxemia. What answer by the nurse instructor is best?
a. It is chronic hypoxemia that accompanies restrictive airway disease.
b. It is hypoxemia from lung damage due to mechanical ventilation.
c. It is hypoxemia that continues even after the client is weaned from oxygen.
d. It is hypoxemia that persists even with 100 oxygen administration.
Question 6A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82, and the client is cyanotic.
What action by the nurse is the priority?
a.
Administer oxygen and reassess.
b.
Auscultate the client's lung sounds.
c.
Facilitate a portable chest x-ray.
d.
Prepare to assist with intubation.
Question 7A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
a. Alteplase (Activase)
b. Enoxaparin (Lovenox)
c. Unfractionated heparin
d. Warfarin sodium (Coumadin)
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