CMV Final (all TB+evolve) UPDATED
ACTUAL Exam Questions and CORRECT
Answers
.A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and
having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes
priority?
a. Assess the clients lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs. - CORRECT ANSWER - ANS: B
This client has manifestations of a pulmonary embolism, and the most critical action is to notify
the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate
also but are not the priority.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active
and has no known risk factors for PE. What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found. - CORRECT ANSWER -
ANS: C
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events,
including PE. A client with no known risk factors for this disorder should be referred for testing.
Encouraging the client to walk is healthy, but is not related to the development of a PE in this
case, nor is smoking. Although there are cases of disease where no cause is ever found, this
assumption is premature.
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the
clients oxygen saturation has not significantly improved. What response by the nurse is best?
a. Breathing so rapidly interferes with oxygenation.
b. Maybe the client has respiratory distress syndrome.
c. The blood clot interferes with perfusion in the lungs.
,d. The client needs immediate intubation and mechanical ventilation. - CORRECT
ANSWER - ANS:
C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless
the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with
oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and
this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but
this is not as likely. The client may need to be mechanically ventilated, but without concrete data
on FiO2 and SaO2 , the nurse cannot make that judgment.
4.A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent
partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin (Coumadin). - CORRECT ANSWER - ANS: B
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the
heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The
heparin rate needs to be increased. Warfarin is not indicated in this situation
.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?
a. Instruct the client to eliminate all vitamin K from the diet.
b. Prepare preoperative teaching for an inferior vena cava (IVC) filter.
c. Refer the client to a chronic illness support group.
d. Teach the client to use a soft-bristled toothbrush - CORRECT ANSWER - ANS: B
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?
a. Hemoglobin: 14.2 g/dL
b. Platelet count: 82,000/L
c. Red blood cell count: 4.8/mm3
d. White blood cell count: 8.7/mm3 - CORRECT ANSWER - ANS: B
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?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply.
d. Tell the client to take slow, deep breaths. - CORRECT ANSWER - ANS: A
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?
a. Ensure the client has adequate sedation.
b. Find another provider to intubate.
c. Interrupt the procedure to give oxygen.
d. Monitor the clients oxygen saturation. - CORRECT ANSWER - ANS: C
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 clients oxygen saturation, but
these do not take priority. Finding another provider is not appropriate at this time.
, An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes
priority?
a. Determine if the tube is kinked.
b. Ensure all connections are patent.
c. Listen to the clients lung sounds.
d. Suction the endotracheal tube - CORRECT ANSWER - ANS: C
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)?
a. Assess the client for sedation needs.
b. Get family permission for restraints.
c. Provide frequent oral care per protocol.
d. Use nonverbal pain assessment tools. - CORRECT ANSWER - ANS: C
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 as a priority?
a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate humidification.
c. The upper peak airway pressure limit alarm is off.
d. The upper peak airway pressure limit alarm is on. - CORRECT ANSWER - ANS: D
The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset
maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off.
Initiating spontaneous breathing is important for some modes of ventilation but not others.
Adequate humidification is important but does not take priority over preventing injury.
ACTUAL Exam Questions and CORRECT
Answers
.A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and
having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes
priority?
a. Assess the clients lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs. - CORRECT ANSWER - ANS: B
This client has manifestations of a pulmonary embolism, and the most critical action is to notify
the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate
also but are not the priority.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active
and has no known risk factors for PE. What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes. c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found. - CORRECT ANSWER -
ANS: C
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events,
including PE. A client with no known risk factors for this disorder should be referred for testing.
Encouraging the client to walk is healthy, but is not related to the development of a PE in this
case, nor is smoking. Although there are cases of disease where no cause is ever found, this
assumption is premature.
A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the
clients oxygen saturation has not significantly improved. What response by the nurse is best?
a. Breathing so rapidly interferes with oxygenation.
b. Maybe the client has respiratory distress syndrome.
c. The blood clot interferes with perfusion in the lungs.
,d. The client needs immediate intubation and mechanical ventilation. - CORRECT
ANSWER - ANS:
C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless
the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with
oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and
this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but
this is not as likely. The client may need to be mechanically ventilated, but without concrete data
on FiO2 and SaO2 , the nurse cannot make that judgment.
4.A client is on intravenous heparin to treat a pulmonary embolism. The clients most recent
partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin (Coumadin). - CORRECT ANSWER - ANS: B
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the
heparin is working. A normal PTT is 25 to 35 seconds, so this clients PTT value is too low. The
heparin rate needs to be increased. Warfarin is not indicated in this situation
.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?
a. Instruct the client to eliminate all vitamin K from the diet.
b. Prepare preoperative teaching for an inferior vena cava (IVC) filter.
c. Refer the client to a chronic illness support group.
d. Teach the client to use a soft-bristled toothbrush - CORRECT ANSWER - ANS: B
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?
a. Hemoglobin: 14.2 g/dL
b. Platelet count: 82,000/L
c. Red blood cell count: 4.8/mm3
d. White blood cell count: 8.7/mm3 - CORRECT ANSWER - ANS: B
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?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply.
d. Tell the client to take slow, deep breaths. - CORRECT ANSWER - ANS: A
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?
a. Ensure the client has adequate sedation.
b. Find another provider to intubate.
c. Interrupt the procedure to give oxygen.
d. Monitor the clients oxygen saturation. - CORRECT ANSWER - ANS: C
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 clients oxygen saturation, but
these do not take priority. Finding another provider is not appropriate at this time.
, An intubated clients oxygen saturation has dropped to 88%. What action by the nurse takes
priority?
a. Determine if the tube is kinked.
b. Ensure all connections are patent.
c. Listen to the clients lung sounds.
d. Suction the endotracheal tube - CORRECT ANSWER - ANS: C
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)?
a. Assess the client for sedation needs.
b. Get family permission for restraints.
c. Provide frequent oral care per protocol.
d. Use nonverbal pain assessment tools. - CORRECT ANSWER - ANS: C
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 as a priority?
a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate humidification.
c. The upper peak airway pressure limit alarm is off.
d. The upper peak airway pressure limit alarm is on. - CORRECT ANSWER - ANS: D
The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset
maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off.
Initiating spontaneous breathing is important for some modes of ventilation but not others.
Adequate humidification is important but does not take priority over preventing injury.
