Exam 7: Chapters 28, 31, 32
1. A nurse is assessing a client who has a pulmonary embolism. Which of the clinical
manifestations should the nurse expect to find? (Select all that apply)
https://quizlet.com/127301096/ati-med-surge-ch-24-pulmonary-embolism-flash-cards/
A. Bradypnea
B. Pleural friction rub
C. Hypertension
D. Petechiae
E. Tachycardia
Ans: B, D, E
2. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The
client states that she is anxious because she feels that she cannot get enough air. Vital signs are:
HR 117/min, RR 38/min, temp 38.4 (101.2), BP 100/54. Which of the following actions is the
priority action at this time?
A. Notify the provider
B. Administer heparin via IV infusion
C. Administer oxygen therapy
D. Obtain a spiral CT scan
Ans: C
3. A nurse is caring for several clients. Which of the following clients are at risk for having a
pulmonary embolism? (Select all that apply) https://quizlet.com/127301096/ati-med-surge-ch-
24-pulmonary-embolism-flash-cards/
A. A client who has a BMI of 30
B. A female client who has postmenopausal
C. A client who has a fractured femur
D. A client who is a marathon runner
E. A client who has chronic atrial fibrillation
Ans: ACE
4. 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 which of the following interventions? https://quizlet.com/270487009/post-trauma-
flash-cards/
A. Obtain a cardiology consult
B. Perform pre-oxygenation prior to suctioning
C. Suction the client less frequently
D. Administer antidysrhythmic
Ans: B
, 5. A nurse in the emergency department is caring for a client who was admitted with an acute
asthma attack. Which of the following indicates the client's respiratory status is declining?
(Select all that apply.) https://quizlet.com/151679317/nclex-ati-comp-respiratory-system-flash-
cards/
A. SaO2 95%
B. Wheezing
C. Retraction of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVCs- correct- but not an option on the test) (Crackles was
option E on the test)
Ans: BC
6. A nurse is orienting a newly licensed nurse on performing routine assessment of a client who
is receiving mechanical ventilation via an endotracheal tube. Which of the following should the
nurse include in the teaching?
A. Apply a vest restraint if self-extubation is attempted.
B. Monitor ventilator settings every 8 hr.
C. Document tube placement in centimeters at the angle of jaw.
D. Assess breath sounds every 1 to 2 hr.
Ans: D
7. An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that
evening, the UAP reports that the client had a coughing spell during the meal. What action by the
nurse takes priority?
a. Assess the client's lung sounds.
b. Assign a different UAP to the client.
c. Report the UAP to the manager.
d. Request thicker liquids for meals.
Ans: A
8. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy
tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings
are noted. What action by the nurse is most appropriate?
a. Call the operating room to inform them of a pending emergency case.
b. No action is needed at this time; this is a normal finding in some clients.
c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
d. Stay with the client and have someone else call the provider immediately.
Ans: D
1. A nurse is assessing a client who has a pulmonary embolism. Which of the clinical
manifestations should the nurse expect to find? (Select all that apply)
https://quizlet.com/127301096/ati-med-surge-ch-24-pulmonary-embolism-flash-cards/
A. Bradypnea
B. Pleural friction rub
C. Hypertension
D. Petechiae
E. Tachycardia
Ans: B, D, E
2. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The
client states that she is anxious because she feels that she cannot get enough air. Vital signs are:
HR 117/min, RR 38/min, temp 38.4 (101.2), BP 100/54. Which of the following actions is the
priority action at this time?
A. Notify the provider
B. Administer heparin via IV infusion
C. Administer oxygen therapy
D. Obtain a spiral CT scan
Ans: C
3. A nurse is caring for several clients. Which of the following clients are at risk for having a
pulmonary embolism? (Select all that apply) https://quizlet.com/127301096/ati-med-surge-ch-
24-pulmonary-embolism-flash-cards/
A. A client who has a BMI of 30
B. A female client who has postmenopausal
C. A client who has a fractured femur
D. A client who is a marathon runner
E. A client who has chronic atrial fibrillation
Ans: ACE
4. 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 which of the following interventions? https://quizlet.com/270487009/post-trauma-
flash-cards/
A. Obtain a cardiology consult
B. Perform pre-oxygenation prior to suctioning
C. Suction the client less frequently
D. Administer antidysrhythmic
Ans: B
, 5. A nurse in the emergency department is caring for a client who was admitted with an acute
asthma attack. Which of the following indicates the client's respiratory status is declining?
(Select all that apply.) https://quizlet.com/151679317/nclex-ati-comp-respiratory-system-flash-
cards/
A. SaO2 95%
B. Wheezing
C. Retraction of sternal muscles
D. Pink mucous membranes
E. Premature ventricular complexes (PVCs- correct- but not an option on the test) (Crackles was
option E on the test)
Ans: BC
6. A nurse is orienting a newly licensed nurse on performing routine assessment of a client who
is receiving mechanical ventilation via an endotracheal tube. Which of the following should the
nurse include in the teaching?
A. Apply a vest restraint if self-extubation is attempted.
B. Monitor ventilator settings every 8 hr.
C. Document tube placement in centimeters at the angle of jaw.
D. Assess breath sounds every 1 to 2 hr.
Ans: D
7. An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that
evening, the UAP reports that the client had a coughing spell during the meal. What action by the
nurse takes priority?
a. Assess the client's lung sounds.
b. Assign a different UAP to the client.
c. Report the UAP to the manager.
d. Request thicker liquids for meals.
Ans: A
8. A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy
tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings
are noted. What action by the nurse is most appropriate?
a. Call the operating room to inform them of a pending emergency case.
b. No action is needed at this time; this is a normal finding in some clients.
c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask.
d. Stay with the client and have someone else call the provider immediately.
Ans: D
