NUR 114 Iggy Perfusion Practice Questions And
Answers With Verified Tests
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 client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs ANS 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. ANS 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 client's 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." ANS 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.
,A client is on intravenous heparin to treat a pulmonary embolism. The client's 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). ANS 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 client's 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. ANS 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 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) ANS ANS:A
Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse
knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not
indicated in this setting.
A 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. ANS ANS: B
This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the client's
presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this
test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client
is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a
diagnosis of PE.
A 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 ANS ANS: B,D,E
, Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous
catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism,
smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma.
A contrast dye reaction and asthma pose no risk for PE.
When working with women who are taking hormonal birth control, what health promotion measures should
the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
a. Avoid drinking alcohol.
b. Eat more omega-3 fatty acids.
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes. ANS ANS: C,D,E
Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a
healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods
containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.
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. ANS ANS: A,B,C,E
Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures,
give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also
reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to
hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is
no evidence that this is the case.
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment
finding should the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min ANS ANS:A
Answers With Verified Tests
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 client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs ANS 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. ANS 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 client's 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." ANS 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.
,A client is on intravenous heparin to treat a pulmonary embolism. The client's 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). ANS 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 client's 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. ANS 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 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) ANS ANS:A
Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse
knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not
indicated in this setting.
A 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. ANS ANS: B
This client has manifestations of pulmonary embolism (PE); however, many conditions can cause the client's
presentation. The gold standard for diagnosing a PE is pulmonary angiography. The nurse should facilitate this
test as soon as possible. The client does not have wheezing, so a respiratory treatment is not needed. The client
is not unstable enough to need intubation and mechanical ventilation. IV anticoagulants are not given without a
diagnosis of PE.
A 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 ANS ANS: B,D,E
, Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous
catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism,
smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma.
A contrast dye reaction and asthma pose no risk for PE.
When working with women who are taking hormonal birth control, what health promotion measures should
the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.)
a. Avoid drinking alcohol.
b. Eat more omega-3 fatty acids.
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes. ANS ANS: C,D,E
Health promotion measures for clients to prevent thromboembolic events such as PE include maintaining a
healthy weight, exercising on a regular basis, and not smoking. Avoiding alcohol and eating more foods
containing omega-3 fatty acids are heart-healthy actions but do not relate to the prevention of PE.
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. ANS ANS: A,B,C,E
Clients with PEs are often anxious. The nurse can acknowledge the client's fears, delegate comfort measures,
give simple explanations the client will understand, and stay with the client. Using a calm, quiet voice is also
reassuring. Sedatives and antianxiety medications are not used routinely because they can contribute to
hypoxia. If the client's anxiety is interfering with diagnostic testing or treatment, they can be used, but there is
no evidence that this is the case.
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment
finding should the nurse expect?
a. Heart rate of 120 beats/min
b. Cool, clammy skin
c. Oxygen saturation of 90%
d. Respiratory rate of 8 breaths/min ANS ANS:A
