NCLEX QUESTIONS DVT PE CF EXAM QUESTIONS AND ANSWERS
A nurse is caring for several clients. Which of the following clients are at risk for having pulmonary
embolism? (Select all that apply)(med-surg pg 263)
A. Client who has BMI of 30
B. Female client who is postmenopausal
C. Client who has a fractured femur
D. Client who is marathon runner
E. Client who has chronic A-FIB - CORRECT ANSWER✅✅a. Client who has BMI of 30
B. Female client who is postmenopausal
c. Client who has a fractured femur
D. Client who is marathon runner
e. Client who has chronic A-FIB
A nurse is reviewing prescriptions for client who has SOB, diaphoresis. Client says feels anxious and cant
get enough air. VS: HR-117/min, RESP-38/min, TEMP-101.2F, BP-100/54mmHg. What is priority action at
this time? (med-surg pg 263)
A. Notify provider
B. Administer heparin IV infusion
C. Administer oxygen therapy
D. Obtain spiral CT scan - CORRECT ANSWER✅✅A. Notify provider
B. Administer heparin IV infusion
c. Administer oxygen therapy
D. Obtain spiral CT scan
A nurse is caring for client who has a new prescription for heparin therapy. What statement by client is
an immediate concern for nurse? (med-surg pg 263)
A. I am allergic to morphine
B. I take antacids several times a day
C. I had a blood clot in my leg several years ago
D. It hurts to take deep breaths - CORRECT ANSWER✅✅A. I am allergic to morphine
, b. I take antacids several times a day
C. I had a blood clot in my leg several years ago
D. It hurts to take deep breaths
A nurse is assessing a client who has pulmonary embolism. What are S/S should nurse expect to find?
(select all that apply)(med-surg pg 263)
A. Bradypnea (slow breathing)
B. Pleural friction rub (raspy sound on exhale)
C. Hypertension (high BP)
D. Petechiae (red/purple spots on chest area)
E. Tachycardia (rapid HR) - CORRECT ANSWER✅✅A. Bradypnea (slow breathing)
b. Pleural friction rub (raspy sound on exhale)
C. Hypertension (high BP)
d. Petechiae (red/purple spots on chest area)
e. Tachycardia (rapid HR)
A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy (tPA). What should the
nurse recognize as contraindication to therapy? (med-surg pg 263)
A. hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exercise-induced asthma 1 week ago
D. Elevated platelet count - CORRECT ANSWER✅✅a. hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exercise-induced asthma 1 week ago
D. Elevated platelet count
A nurse is planning to administer subcutaneous enoxaparin (lovenox) to an adult client following hip
arthroplasty. Which action should the nurse plan to take?
A. Choose 22-gauge needle to administer
B. Use 5/8 inch needle to administer
A nurse is caring for several clients. Which of the following clients are at risk for having pulmonary
embolism? (Select all that apply)(med-surg pg 263)
A. Client who has BMI of 30
B. Female client who is postmenopausal
C. Client who has a fractured femur
D. Client who is marathon runner
E. Client who has chronic A-FIB - CORRECT ANSWER✅✅a. Client who has BMI of 30
B. Female client who is postmenopausal
c. Client who has a fractured femur
D. Client who is marathon runner
e. Client who has chronic A-FIB
A nurse is reviewing prescriptions for client who has SOB, diaphoresis. Client says feels anxious and cant
get enough air. VS: HR-117/min, RESP-38/min, TEMP-101.2F, BP-100/54mmHg. What is priority action at
this time? (med-surg pg 263)
A. Notify provider
B. Administer heparin IV infusion
C. Administer oxygen therapy
D. Obtain spiral CT scan - CORRECT ANSWER✅✅A. Notify provider
B. Administer heparin IV infusion
c. Administer oxygen therapy
D. Obtain spiral CT scan
A nurse is caring for client who has a new prescription for heparin therapy. What statement by client is
an immediate concern for nurse? (med-surg pg 263)
A. I am allergic to morphine
B. I take antacids several times a day
C. I had a blood clot in my leg several years ago
D. It hurts to take deep breaths - CORRECT ANSWER✅✅A. I am allergic to morphine
, b. I take antacids several times a day
C. I had a blood clot in my leg several years ago
D. It hurts to take deep breaths
A nurse is assessing a client who has pulmonary embolism. What are S/S should nurse expect to find?
(select all that apply)(med-surg pg 263)
A. Bradypnea (slow breathing)
B. Pleural friction rub (raspy sound on exhale)
C. Hypertension (high BP)
D. Petechiae (red/purple spots on chest area)
E. Tachycardia (rapid HR) - CORRECT ANSWER✅✅A. Bradypnea (slow breathing)
b. Pleural friction rub (raspy sound on exhale)
C. Hypertension (high BP)
d. Petechiae (red/purple spots on chest area)
e. Tachycardia (rapid HR)
A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy (tPA). What should the
nurse recognize as contraindication to therapy? (med-surg pg 263)
A. hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exercise-induced asthma 1 week ago
D. Elevated platelet count - CORRECT ANSWER✅✅a. hip arthroplasty 2 weeks ago
B. Elevated sedimentation rate
C. Incident of exercise-induced asthma 1 week ago
D. Elevated platelet count
A nurse is planning to administer subcutaneous enoxaparin (lovenox) to an adult client following hip
arthroplasty. Which action should the nurse plan to take?
A. Choose 22-gauge needle to administer
B. Use 5/8 inch needle to administer
