N480 FINAL EXAM QUESTIONS AND ANSWERS
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 - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT
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? -
CORRECT 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? - CORRECT
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? - CORRECT 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? - CORRECT
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? - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT
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? - CORRECT 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? -
CORRECT ANSWER✅✅Pacemaker spikes before each QRS complex
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 - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT
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? -
CORRECT 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? - CORRECT
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? - CORRECT 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? - CORRECT
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? - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT 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? - CORRECT
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? - CORRECT 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? -
CORRECT ANSWER✅✅Pacemaker spikes before each QRS complex
