N480 FINAL EXAM QUESTIONS WITH COMPLETE
SOLUTIONS.
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 Answer -
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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer -
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? Answer - 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?
Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer
- 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
Answer - Cracks in oral mucous membranes
SOLUTIONS.
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 Answer -
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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer -
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? Answer - 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?
Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer - 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? Answer
- 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
Answer - Cracks in oral mucous membranes
