CHII Exam 1 Questions and Answers Already Passed
Which laboratory values are most important for a nurse to monitor for a client who is receiving a
heparin infusion for treatment of a pulmonary embolism when warfarin is added to the drug therapy?
Select all that apply.
A. Activated partial thromboplastin time
B. Albumin levels
C. Factor V levels
D. Hepatic function tests
E. International normalized ratio
F. Platelet count
G. Serum osmolarity - Answers A,E,F (heparin aPTT, warfarin = INR, both = platelet count)
The nurse is troubleshooting multiple ventilator alarms sounding for a client who is intubated and being
mechanically ventilated. The alarms persist despite suctioning, repositioning the client, and ensuring
that the ventilator tubing is unobstructed. Which actions will the nurse perform next? Select all that
apply.
A. Turn off all ventilator alarms until a cause is found to prevent scaring the client.
B. Page the primary health care provider to request additional sedation.
C. Ensure that the endotracheal tube marking is at the client's incisor.
D. Increase the PEEP to improve GAS EXCHANGE.
E. Disconnect the client from the ventilator and use the manual resuscitation bag.
F. Change all ventilator tubing.
G. Stat page the respiratory therapist.
H. Determine when the client received the last dose of the paralytic agent. - Answers c,e,g
During routine suctioning of a client with a tracheostomy, the client becomes diaphoretic and nauseous,
and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?
A. Continue to clear the airway.
B. Stop suctioning the patient.
C. Administer atropine.
,D. Call the health care provider immediately. - Answers b. stop suctioning
he primary health care provider prescribes warfarin (Coumadin) for a client with atrial fibrillation. Which
statement made by the client indicates that additional education is needed?
A. "I need to go to the clinic once a week to have my blood level checked."
B. "If my stools turn black, I will be sure to call my primary health care provider"
C. "I'm glad I don't need to change my diet. Salads are my favorite food."
D. "I need to stop taking my herbal supplement." - Answers c. diet change is necessary
A client in the telemetry unit is on a cardiac monitor. The monitor technician notices that there are no
ECG complexes, and the alarm sounds. What is the first action by the nurse?
A. Suspend the alarm.
B. Call the emergency response team.
C. Press the record button to get an ECG strip.
D. Assess the client and check lead placement - Answers d. check on your patient (we treat patients not
monitors)
A client who recently had a heart valve replacement is preparing for discharge. Which statement by the
client indicates that the nurse will need to do additional health teaching?
A. "I need to brush my teeth at least twice daily and rinse with water."
B. "I'll eat foods that are low in vitamin K, such as potatoes and iceberg lettuce."
C. "I need to take a full course of antibiotics before my colonoscopy."
D. "I'll take my blood pressure every day and call if it is too high or low." - Answers c. (Antibiotics are
only required prior to dental procedures b/c of risk for developing infective endocarditis)
With which client should the nurse remain alert for the possibility of sepsis and septic shock?
A. 41-year-old man who sustained closed depression fractures of the face when hit with a baseball
B. 53-year-old woman who had an open abdominal hysterectomy 3 days ago to remove severe large
fibroid tumors.
C. 67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago.
D. 72-year-old man with severe allergies who is undergoing radiation therapy for early-stage prostate
cancer. - Answers c
, A 48-year-old female client having an annual physical asks the nurse about her risk for developing a
myocardial infarction (MI). The nurse discusses risk factors with the client.Which modifiable risk factors
will the nurse assess to guide the client's teaching plan? Select all that apply.
A. Older age
B. Tobacco use
C. Female
D. High-fat diet
E. Family history
F. Obesity - Answers b,d,f
The nurse is assessing a client with chest pain. Which symptoms assessed by the nurse would be most
indicative of myocardial infarction? Select all that apply.
A. Substernal chest discomfort associated with exertion
B. Chest pain that is relieved with rest.
C. Chest pain associated with ECG changes
D. Chest pain relieved with nitroglycerin
E. Chest pain relieved only by opioids
F. Chest pain associated with shortness of breath
G. Chest pain that lasts less than 10 minutes - Answers c,d,f?
The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding
will cause the nurse to suspect cardiac tamponade?
A. Incisional pain with decreased urine output
B. Muffled heart sounds with the presence of jugular venous distention (JVD)
C. Sternal wound drainage with nausea
D. Increased blood pressure and decreased heart rate - Answers b
Which statement made by the client on the way to the catheterization laboratory requires an immediate
action by the nurse?
A. "My allergies are bothering me, so I took some Benadryl last night before bed."
Which laboratory values are most important for a nurse to monitor for a client who is receiving a
heparin infusion for treatment of a pulmonary embolism when warfarin is added to the drug therapy?
Select all that apply.
A. Activated partial thromboplastin time
B. Albumin levels
C. Factor V levels
D. Hepatic function tests
E. International normalized ratio
F. Platelet count
G. Serum osmolarity - Answers A,E,F (heparin aPTT, warfarin = INR, both = platelet count)
The nurse is troubleshooting multiple ventilator alarms sounding for a client who is intubated and being
mechanically ventilated. The alarms persist despite suctioning, repositioning the client, and ensuring
that the ventilator tubing is unobstructed. Which actions will the nurse perform next? Select all that
apply.
A. Turn off all ventilator alarms until a cause is found to prevent scaring the client.
B. Page the primary health care provider to request additional sedation.
C. Ensure that the endotracheal tube marking is at the client's incisor.
D. Increase the PEEP to improve GAS EXCHANGE.
E. Disconnect the client from the ventilator and use the manual resuscitation bag.
F. Change all ventilator tubing.
G. Stat page the respiratory therapist.
H. Determine when the client received the last dose of the paralytic agent. - Answers c,e,g
During routine suctioning of a client with a tracheostomy, the client becomes diaphoretic and nauseous,
and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?
A. Continue to clear the airway.
B. Stop suctioning the patient.
C. Administer atropine.
,D. Call the health care provider immediately. - Answers b. stop suctioning
he primary health care provider prescribes warfarin (Coumadin) for a client with atrial fibrillation. Which
statement made by the client indicates that additional education is needed?
A. "I need to go to the clinic once a week to have my blood level checked."
B. "If my stools turn black, I will be sure to call my primary health care provider"
C. "I'm glad I don't need to change my diet. Salads are my favorite food."
D. "I need to stop taking my herbal supplement." - Answers c. diet change is necessary
A client in the telemetry unit is on a cardiac monitor. The monitor technician notices that there are no
ECG complexes, and the alarm sounds. What is the first action by the nurse?
A. Suspend the alarm.
B. Call the emergency response team.
C. Press the record button to get an ECG strip.
D. Assess the client and check lead placement - Answers d. check on your patient (we treat patients not
monitors)
A client who recently had a heart valve replacement is preparing for discharge. Which statement by the
client indicates that the nurse will need to do additional health teaching?
A. "I need to brush my teeth at least twice daily and rinse with water."
B. "I'll eat foods that are low in vitamin K, such as potatoes and iceberg lettuce."
C. "I need to take a full course of antibiotics before my colonoscopy."
D. "I'll take my blood pressure every day and call if it is too high or low." - Answers c. (Antibiotics are
only required prior to dental procedures b/c of risk for developing infective endocarditis)
With which client should the nurse remain alert for the possibility of sepsis and septic shock?
A. 41-year-old man who sustained closed depression fractures of the face when hit with a baseball
B. 53-year-old woman who had an open abdominal hysterectomy 3 days ago to remove severe large
fibroid tumors.
C. 67-year-old woman on chronic corticosteroid therapy who had several teeth extracted 2 days ago.
D. 72-year-old man with severe allergies who is undergoing radiation therapy for early-stage prostate
cancer. - Answers c
, A 48-year-old female client having an annual physical asks the nurse about her risk for developing a
myocardial infarction (MI). The nurse discusses risk factors with the client.Which modifiable risk factors
will the nurse assess to guide the client's teaching plan? Select all that apply.
A. Older age
B. Tobacco use
C. Female
D. High-fat diet
E. Family history
F. Obesity - Answers b,d,f
The nurse is assessing a client with chest pain. Which symptoms assessed by the nurse would be most
indicative of myocardial infarction? Select all that apply.
A. Substernal chest discomfort associated with exertion
B. Chest pain that is relieved with rest.
C. Chest pain associated with ECG changes
D. Chest pain relieved with nitroglycerin
E. Chest pain relieved only by opioids
F. Chest pain associated with shortness of breath
G. Chest pain that lasts less than 10 minutes - Answers c,d,f?
The nurse assesses a client who had a coronary artery bypass graft yesterday. Which assessment finding
will cause the nurse to suspect cardiac tamponade?
A. Incisional pain with decreased urine output
B. Muffled heart sounds with the presence of jugular venous distention (JVD)
C. Sternal wound drainage with nausea
D. Increased blood pressure and decreased heart rate - Answers b
Which statement made by the client on the way to the catheterization laboratory requires an immediate
action by the nurse?
A. "My allergies are bothering me, so I took some Benadryl last night before bed."
