N480 Final Exam Questions and Answers Fully Solved Latest Version 2025-2026
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart
rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the
client requires - Answers preoxygenation prior to suctioning
After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP)
monitor indicates low pressures. Which action should the nurse take? - Answers Increase the IV
fluid infusion per protocol
A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a
client who has acute respiratory distress syndrome (ARDS). Which of the following statements
by the newly licensed nurse indicates understanding of the teaching? - Answers This medication
is given to facilitate ventilation
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse when
sexual intercourse can be resumed. Which response by the nurse is best? - Answers Sexual
activity uses about as much energy as climbing two flights of stairs
A nurse is caring for a client who came to the ED reporting chest pain. The provider suspects a
myocardial infarction. While waiting for the troponin levels report, the client asks what this
blood test will show. Which of the following explanations should the nurse provide the client? -
Answers Troponin is a heart muscle protein that appears in the bloodstream when there is
damage to the heart
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the
following actions should the nurse take to determine if the client is experiencing a myocardial
infarction? - Answers Perform a 12-lead ECG
The nurse assesses a client with dyspnea, decreased breath sounds, tracheal deviation, and
pulse oximetry reading of 86%. What is the nurse's interpretation of these findings? - Answers
Tension pneumothorax
What action by a new intensive care unit staff nurse would indicate that the nurse educator's
teaching about arterial pressure monitoring has been effective? - Answers Positions the zero-
reference stopcock line level with the phlebostatic axis
A nurse is caring for a client who is receiving heparin by continuous IV fusion. Which of the
following meds should the nurse plan to administer in the event of an overdose? - Answers
Protamine sulfate
Which finding by the nurse caring for a patient with a right radial arterial line indicates a need for
the nurse to take immediate action? - Answers The right hand feels cooler than the left hand
Which statement by the nurse when explaining the purpose of positive end expiratory pressure
, (PEEP) to the patient's caregiver is accurate? - Answers PEEP prevents the lung air sacs from
collapsing during exhalation
A nurse is planning the discharge of the client who has sleep apnea and requires bi-level
positive airway pressure (BIPAP) at night. The nurse should plan to consult with which of the
following health care team members to help educate the client? - Answers Respiratory therapist
A nurse is caring for a 76 yr old client who has a recently placed central venous catheter and
reports hearing a gurgling sound on the side of the catheter insertion. Which of the following
complications should the nurse suspect? - Answers Catheter migration
The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment
depression and T-wave inversion. What should the nurse know that this indicates? - Answers
Myocardial ischemia
The nursing student is asked to demonstrate the Allen test on a fellow student. Which of the
following best describes the Allen test? - Answers Test used to determine patency of the radial
and ulnar arteries
A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse
understands
that the pacemaker is functioning properly when which of the following appears on the monitor
strip? - Answers Pacemaker spikes before each QRS complex
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325mg. The nurse
recognizes that the aspirin is given due to which of the following actions of the medication? -
Answers Antiplatelet aggregate
A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable
pulses. What actions should the nurse take next? - Answers Start CPR
A nurse is caring for a client who has been receiving oxygen therapy for several days. When
assessing the client, the nurse should identify which of the following findings as an indication of
an adverse effect of oxygen therapy - Answers Cracks in oral mucous membranes
The nurse is caring for a postoperative patient who has a chest tube connected to suction and a
water seal drainage system. Which of the following indicates to the nurse that the chest tube is
functioning properly? - Answers Fluctuation of the fluid level within the water seal chamber
A recently admitted 36 year old patient who has sustained multiple traumas develops a low CVP
pressure. Which of the following interpretations will alert the nurse of this change? - Answers
Hypovolemia
A nurse in an ED is planning care for a client who is having acute myocardial infarction (MI). The
nurse should plan to administer which of the following medications after the initial acute phase
A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart
rate increases from 86/min to 110/min and becomes irregular. The nurse should know that the
client requires - Answers preoxygenation prior to suctioning
After surgery for an abdominal aortic aneurysm, a patient's central venous pressure (CVP)
monitor indicates low pressures. Which action should the nurse take? - Answers Increase the IV
fluid infusion per protocol
A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a
client who has acute respiratory distress syndrome (ARDS). Which of the following statements
by the newly licensed nurse indicates understanding of the teaching? - Answers This medication
is given to facilitate ventilation
A patient who is recovering from an acute myocardial infarction (AMI) asks the nurse when
sexual intercourse can be resumed. Which response by the nurse is best? - Answers Sexual
activity uses about as much energy as climbing two flights of stairs
A nurse is caring for a client who came to the ED reporting chest pain. The provider suspects a
myocardial infarction. While waiting for the troponin levels report, the client asks what this
blood test will show. Which of the following explanations should the nurse provide the client? -
Answers Troponin is a heart muscle protein that appears in the bloodstream when there is
damage to the heart
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the
following actions should the nurse take to determine if the client is experiencing a myocardial
infarction? - Answers Perform a 12-lead ECG
The nurse assesses a client with dyspnea, decreased breath sounds, tracheal deviation, and
pulse oximetry reading of 86%. What is the nurse's interpretation of these findings? - Answers
Tension pneumothorax
What action by a new intensive care unit staff nurse would indicate that the nurse educator's
teaching about arterial pressure monitoring has been effective? - Answers Positions the zero-
reference stopcock line level with the phlebostatic axis
A nurse is caring for a client who is receiving heparin by continuous IV fusion. Which of the
following meds should the nurse plan to administer in the event of an overdose? - Answers
Protamine sulfate
Which finding by the nurse caring for a patient with a right radial arterial line indicates a need for
the nurse to take immediate action? - Answers The right hand feels cooler than the left hand
Which statement by the nurse when explaining the purpose of positive end expiratory pressure
, (PEEP) to the patient's caregiver is accurate? - Answers PEEP prevents the lung air sacs from
collapsing during exhalation
A nurse is planning the discharge of the client who has sleep apnea and requires bi-level
positive airway pressure (BIPAP) at night. The nurse should plan to consult with which of the
following health care team members to help educate the client? - Answers Respiratory therapist
A nurse is caring for a 76 yr old client who has a recently placed central venous catheter and
reports hearing a gurgling sound on the side of the catheter insertion. Which of the following
complications should the nurse suspect? - Answers Catheter migration
The patient is admitted with acute coronary syndrome (ACS). The ECG shows ST-segment
depression and T-wave inversion. What should the nurse know that this indicates? - Answers
Myocardial ischemia
The nursing student is asked to demonstrate the Allen test on a fellow student. Which of the
following best describes the Allen test? - Answers Test used to determine patency of the radial
and ulnar arteries
A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse
understands
that the pacemaker is functioning properly when which of the following appears on the monitor
strip? - Answers Pacemaker spikes before each QRS complex
A client who has a history of myocardial infarction (MI) is prescribed aspirin 325mg. The nurse
recognizes that the aspirin is given due to which of the following actions of the medication? -
Answers Antiplatelet aggregate
A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic, and has no palpable
pulses. What actions should the nurse take next? - Answers Start CPR
A nurse is caring for a client who has been receiving oxygen therapy for several days. When
assessing the client, the nurse should identify which of the following findings as an indication of
an adverse effect of oxygen therapy - Answers Cracks in oral mucous membranes
The nurse is caring for a postoperative patient who has a chest tube connected to suction and a
water seal drainage system. Which of the following indicates to the nurse that the chest tube is
functioning properly? - Answers Fluctuation of the fluid level within the water seal chamber
A recently admitted 36 year old patient who has sustained multiple traumas develops a low CVP
pressure. Which of the following interpretations will alert the nurse of this change? - Answers
Hypovolemia
A nurse in an ED is planning care for a client who is having acute myocardial infarction (MI). The
nurse should plan to administer which of the following medications after the initial acute phase
