Practice Questions for 265 Exam 2
the RN is caring for a pt who is receiving a heparin infusion for treatment of a pulmonary embolism (PE)
which of the following indicates a therapeutic effect of tx? - Correct Answer: D-Dimer level is increased
at 600mg/mL
- shows breakdown of fibrinogen
the RN is caring for a pt who is 4 days postop and suddenly develops difficulty breathing and sharp chest
pain. the RN has called a MRT, raised the HOB and applied O2. which actions should the RN take next? -
Correct Answer: - auscultate the pt's lung sounds
- initiate continuous cardiac monitoring
- connect the pt to continuous pulse oximeter
- assess the pt's skin color
the RN has provided d/c teaching to a pt who developed a pulmonary embolism (PE) following a surgical
procedure. the pt will be taking newly prescribed Warfarin at home. which of the following pt
statements indicates a correct understanding of the teaching? - Correct Answer: "i should avoid
anything rectally, such as enemas or suppositories"
- no enemas, take stool softners, benefiber
the RN is caring for a pt who appears to have developed a pulmonary embolism (PE). which of the
following arterial blood gas results would the RN expect the pt to initially have? - Correct Answer:
pH=7.50, PaO2=79mmHg, PaCO2=32mmHg, HCO3=23mEq/L, SaO2=88%
- respiratory alkalosis
the RN is caring for a pt who has a chest tube. which assessment finding from the box below requires
the RN to immed notify the PHCP? - Correct Answer: - tracheal deviation (closes off the aorta, lose pedal
pulses)
- 100 ml of drainage within an hour (over 70!!!!)
- visibility of the eyelets of the chest tube
, the RN is assessing a pt who has a chest tube places 36 hours ago for the tx of a pneumothorax. the RN
observes continuous bubbling in the water seal chamber. which of the following actions should the RN
take? - Correct Answer: inform the PHCP that there is a leak in the system
the RN is assessing patients for the risk of developing ARDS. the RN should identify at greatest risk is the
pt who...? - Correct Answer: had a stroke and is having difficulty swallowing
the RN has been made aware of the following pt situations. the RN should initially follow up with the pt
who is receiving...? - Correct Answer: mechanical ventilation for the tx of ARDS and has an absence of
breath sounds in the LL lobe
- sx of PNEUMOTHORAX
the RN is caring for a pt who developed ARDS and has been placed on mechanical ventilation. which of
the following is a priority action for the RN to take? - Correct Answer: initiate prescribed TPN
the RN has attended a continuing education program on interdisciplinary care. it would indicate a
correct understanding of the program if the RN identifies that an interdisciplinary conference would be
the most important for the pt who is...? - Correct Answer: either / or
- 34 y/o is single parent, was involved in a motor vehicle crash, and sustained a left hemothorax
- 21 y/o is a college student, has been receiving mechanical ventilation for 14 days for the tx of ARDS
the RN working in the ED is assessing a pt who has a left pneumothorax. which of the following
assessment findings should the RN expect? - Correct Answer: limited (or unequal) chest expansion
the RN is caring for a pt who is receiving mechanical ventilation via ET tube and is unable to speak. the
pts family is frightened that the pt has permanently lost their voice.
which of the following responses should the RN make? - Correct Answer: the tube is causing a
temporary loss of the voice
the RN is caring for a pt who is receiving mechanical ventilation via ET tube. the pt begins to havr a
decrease in gas exchange. the RN should 1st? - Correct Answer: assess for signs of pneumothorax
- check tube placement
- check o2 sat
the RN is caring for a pt who is receiving a heparin infusion for treatment of a pulmonary embolism (PE)
which of the following indicates a therapeutic effect of tx? - Correct Answer: D-Dimer level is increased
at 600mg/mL
- shows breakdown of fibrinogen
the RN is caring for a pt who is 4 days postop and suddenly develops difficulty breathing and sharp chest
pain. the RN has called a MRT, raised the HOB and applied O2. which actions should the RN take next? -
Correct Answer: - auscultate the pt's lung sounds
- initiate continuous cardiac monitoring
- connect the pt to continuous pulse oximeter
- assess the pt's skin color
the RN has provided d/c teaching to a pt who developed a pulmonary embolism (PE) following a surgical
procedure. the pt will be taking newly prescribed Warfarin at home. which of the following pt
statements indicates a correct understanding of the teaching? - Correct Answer: "i should avoid
anything rectally, such as enemas or suppositories"
- no enemas, take stool softners, benefiber
the RN is caring for a pt who appears to have developed a pulmonary embolism (PE). which of the
following arterial blood gas results would the RN expect the pt to initially have? - Correct Answer:
pH=7.50, PaO2=79mmHg, PaCO2=32mmHg, HCO3=23mEq/L, SaO2=88%
- respiratory alkalosis
the RN is caring for a pt who has a chest tube. which assessment finding from the box below requires
the RN to immed notify the PHCP? - Correct Answer: - tracheal deviation (closes off the aorta, lose pedal
pulses)
- 100 ml of drainage within an hour (over 70!!!!)
- visibility of the eyelets of the chest tube
, the RN is assessing a pt who has a chest tube places 36 hours ago for the tx of a pneumothorax. the RN
observes continuous bubbling in the water seal chamber. which of the following actions should the RN
take? - Correct Answer: inform the PHCP that there is a leak in the system
the RN is assessing patients for the risk of developing ARDS. the RN should identify at greatest risk is the
pt who...? - Correct Answer: had a stroke and is having difficulty swallowing
the RN has been made aware of the following pt situations. the RN should initially follow up with the pt
who is receiving...? - Correct Answer: mechanical ventilation for the tx of ARDS and has an absence of
breath sounds in the LL lobe
- sx of PNEUMOTHORAX
the RN is caring for a pt who developed ARDS and has been placed on mechanical ventilation. which of
the following is a priority action for the RN to take? - Correct Answer: initiate prescribed TPN
the RN has attended a continuing education program on interdisciplinary care. it would indicate a
correct understanding of the program if the RN identifies that an interdisciplinary conference would be
the most important for the pt who is...? - Correct Answer: either / or
- 34 y/o is single parent, was involved in a motor vehicle crash, and sustained a left hemothorax
- 21 y/o is a college student, has been receiving mechanical ventilation for 14 days for the tx of ARDS
the RN working in the ED is assessing a pt who has a left pneumothorax. which of the following
assessment findings should the RN expect? - Correct Answer: limited (or unequal) chest expansion
the RN is caring for a pt who is receiving mechanical ventilation via ET tube and is unable to speak. the
pts family is frightened that the pt has permanently lost their voice.
which of the following responses should the RN make? - Correct Answer: the tube is causing a
temporary loss of the voice
the RN is caring for a pt who is receiving mechanical ventilation via ET tube. the pt begins to havr a
decrease in gas exchange. the RN should 1st? - Correct Answer: assess for signs of pneumothorax
- check tube placement
- check o2 sat
