NUR 411 practice exam 3
What is the basis for the decreased oxygen saturation the nurse assesses in a client
with a pulmonary embolism (PE)?
A. Partial bronchial airway obstruction
B. Thickened alveolar membranes and poor gas exchange
C. Increased oxygen need resulting from a septic clot PE
D. Shunting of deoxygenated blood to the left side of the heart - answerD
A PE lodges in the blood vessels decreasing perfusion to a lung area, which wastes
ventilation. When this blood that has not been oxygenated is returned to the left side of
the heart, it dilutes the oxygen concentration of the arterial blood entering systemic
circulation.PE does not block bronchial airways or thicken alveolar membranes. A septic
clot is not the same as general sepsis, which when widespread, does increase tissue
metabolism and the need for more oxygen.
Drugs from which class will the nurse prepare to administer as first-line therapy for a
client just diagnosed with pulmonary embolism (PE)?
A. Anticoagulants
B. Antihypertensives
C. Antidysrhythmics
D. Antibiotics - answerA
A PE is collection of particulate matter (solids, liquids, or air) that enters venous
circulation and lodges in the pulmonary vessels. Anticoagulants are the first-line therapy
drugs for this problem, even if the actual particulate matter is not a clot. Anything lodged
in the blood vessels will cause clot formation around it. Anticoagulants help prevent new
clots from forming in the area and extension of existing clots. Depending on other
problems cause by a PE, antibiotics, or antidysrhythmics may also be used but not
always. Clients with PE are hypotensive, not hypertensive.
Which new assessment finding in a client being managed for a pulmonary embolism
(PE) indicates to the nurse that the client's condition is worsening?
A. Increasing temperature
B. Abdominal cramping
C. Hand tremors
D. Distended neck veins in the high-Fowler position - answerD
Distension of neck veins in the upright (high-Fowler) position occurs with right-sided
heart failure, which is a complication of PE. None of the other changes in assessment
findings are directly associated with worsening PE.
,In addition to the pulmonary health care provider, which other member of the
interprofessional team will the nurse expect to collaborate with most frequently when
providing care to a client with a pulmonary embolism (PE)?
A. Registered dietitian nutritionist
B. Respiratory therapist
C. Occupational therapist (OT)
D. Pharmacist - answerB
The client with a PE has ongoing respiratory problems that change gas exchange
almost hourly and require adjustments in respiratory support. The respiratory therapist
will be collaborating with the nurse and client at least daily. Other team members listed
have roles than change with the client's condition and collaboration is more intermittent.
Which assessment findings in a postoperative client suggest to the nurse the possibility
of a pulmonary embolism (PE) and pulmonary infarction?
A. Hemoptysis and shortness of breath
B. Fever and tracheal deviation
C. Audible wheezing on inhalation and exhalation
D. Paradoxical chest movements - answerA
Symptoms of a PE with infarction include profound shortness of breath and bloody
sputum (hemoptysis) from poor gas exchange and hypoxic damage to lung tissues.
Paradoxical chest movements are associated with a flail chest, not PE. Tracheal
deviation is associated with a pneumothorax. Audible wheezing on inhalation and
exhalation is a partial obstruction of the tracheobronchial tree.
In addition to notifying the pulmonary health care provider, what is the most important
action for the nurse to take first for a client with a pulmonary embolism (PE) whose
arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and
HCO3− 24 mEq/L (24 mmol/L)?
A. Administering sodium bicarbonate
B. Having the client breathe rapidly and deeply into a paper bag
C. Assessing for the presence of adventitious lung sounds
D. Increasing the oxygen flow rate - answerD
These ABG values indicate respiratory acidosis (low pH and high PaCO2) and severe
hypoxemia (low PaO2) from greatly reduced gas exchange. This client needs more
oxygen now.by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg)
and a high pH (7.46). Breathing more rapidly and deeply into a paper bag would
decrease oxygen levels and increase CO2 further, making hypoxemia and acidosis
worse. The bicarbonate level is normal and requires no intervention. Adventitious
sounds are expected and identifying them is not the first priority
Which action is a priority for the nurse to prevent harm for a client with a pulmonary
embolism who is receiving a continuous heparin infusion?
, A. Assessing gums daily for indications of bleeding
B. Monitoring the platelet count daily
C. Assessing breath sounds
D. Comparing pedal pulses bilaterally - answerB
Daily platelet counts are a safety priority in assessing for heparin-induced
thrombocytopenia (HIT), a potential side effect of heparin.Assessing breath sounds
each shift is an important action, as is examining for indications of bleeding. However,
identifying HIT early is a greater priority so that appropriate interventions can be
initiated. Assessing bilateral pedal pulses is important if the source of the embolism is a
venous thromboembolism (VTE) in the legs; however, this is not an important general
action for a client with PE.
Which client will the nurse consider to be at the greatest risk for developing acute
respiratory distress syndrome (ARDS)?
A. A 22 year old with a fractured clavicle
B. A 39 year old with uncontrolled diabetes
C. A 56 year old with chronic kidney disease
D. A 74 year old who aspirates a tube feeding - answerD
ARDS is a type of acute respiratory failure with hypoxemia that persists even when
100% oxygen is given, decreased pulmonary compliance, dyspnea, bilateral pulmonary
edema, and dense pulmonary infiltrates on x-ray (ground-glass appearance). It often
occurs after an acute lung injury such as could result from aspiration of acidic gastric
contents. Clients who are receiving tube feedings are at particular risk for lung damage
by aspiration.Fractured clavicle, diabetes, and chronic kidney disease is associated with
an increased risk for lung injury or ARDS.
What is the primary emphasis for the nurse who is providing care to a client with acute
respiratory distress syndrome (ARDS) currently in the exudative management stage of
the disorder?
A. Assessing the client at least hourly for tachypnea and dyspnea
B. Performing meticulous mouth during mechanical ventilation
C. Assessing for abnormal lung sounds
D. Monitoring urine output to identify multiple organ dysfunction syndrome early -
answerA
The exudative phase includes early changes of dyspnea and tachypnea resulting from
the alveoli becoming fluid filled and from pulmonary shunting and atelectasis. Early
interventions focus on frequent assessment of respiratory status, supporting the client,
and providing oxygen.Abnormal lung sounds are not present at this stage because the
edema is present in the interstitial tissues and not in the airways. At this stage, clients
are neither intubated nor being mechanically ventilated. Multiple organ dysfunction
syndrome is not a feature of this stage.
What is the basis for the decreased oxygen saturation the nurse assesses in a client
with a pulmonary embolism (PE)?
A. Partial bronchial airway obstruction
B. Thickened alveolar membranes and poor gas exchange
C. Increased oxygen need resulting from a septic clot PE
D. Shunting of deoxygenated blood to the left side of the heart - answerD
A PE lodges in the blood vessels decreasing perfusion to a lung area, which wastes
ventilation. When this blood that has not been oxygenated is returned to the left side of
the heart, it dilutes the oxygen concentration of the arterial blood entering systemic
circulation.PE does not block bronchial airways or thicken alveolar membranes. A septic
clot is not the same as general sepsis, which when widespread, does increase tissue
metabolism and the need for more oxygen.
Drugs from which class will the nurse prepare to administer as first-line therapy for a
client just diagnosed with pulmonary embolism (PE)?
A. Anticoagulants
B. Antihypertensives
C. Antidysrhythmics
D. Antibiotics - answerA
A PE is collection of particulate matter (solids, liquids, or air) that enters venous
circulation and lodges in the pulmonary vessels. Anticoagulants are the first-line therapy
drugs for this problem, even if the actual particulate matter is not a clot. Anything lodged
in the blood vessels will cause clot formation around it. Anticoagulants help prevent new
clots from forming in the area and extension of existing clots. Depending on other
problems cause by a PE, antibiotics, or antidysrhythmics may also be used but not
always. Clients with PE are hypotensive, not hypertensive.
Which new assessment finding in a client being managed for a pulmonary embolism
(PE) indicates to the nurse that the client's condition is worsening?
A. Increasing temperature
B. Abdominal cramping
C. Hand tremors
D. Distended neck veins in the high-Fowler position - answerD
Distension of neck veins in the upright (high-Fowler) position occurs with right-sided
heart failure, which is a complication of PE. None of the other changes in assessment
findings are directly associated with worsening PE.
,In addition to the pulmonary health care provider, which other member of the
interprofessional team will the nurse expect to collaborate with most frequently when
providing care to a client with a pulmonary embolism (PE)?
A. Registered dietitian nutritionist
B. Respiratory therapist
C. Occupational therapist (OT)
D. Pharmacist - answerB
The client with a PE has ongoing respiratory problems that change gas exchange
almost hourly and require adjustments in respiratory support. The respiratory therapist
will be collaborating with the nurse and client at least daily. Other team members listed
have roles than change with the client's condition and collaboration is more intermittent.
Which assessment findings in a postoperative client suggest to the nurse the possibility
of a pulmonary embolism (PE) and pulmonary infarction?
A. Hemoptysis and shortness of breath
B. Fever and tracheal deviation
C. Audible wheezing on inhalation and exhalation
D. Paradoxical chest movements - answerA
Symptoms of a PE with infarction include profound shortness of breath and bloody
sputum (hemoptysis) from poor gas exchange and hypoxic damage to lung tissues.
Paradoxical chest movements are associated with a flail chest, not PE. Tracheal
deviation is associated with a pneumothorax. Audible wheezing on inhalation and
exhalation is a partial obstruction of the tracheobronchial tree.
In addition to notifying the pulmonary health care provider, what is the most important
action for the nurse to take first for a client with a pulmonary embolism (PE) whose
arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and
HCO3− 24 mEq/L (24 mmol/L)?
A. Administering sodium bicarbonate
B. Having the client breathe rapidly and deeply into a paper bag
C. Assessing for the presence of adventitious lung sounds
D. Increasing the oxygen flow rate - answerD
These ABG values indicate respiratory acidosis (low pH and high PaCO2) and severe
hypoxemia (low PaO2) from greatly reduced gas exchange. This client needs more
oxygen now.by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg)
and a high pH (7.46). Breathing more rapidly and deeply into a paper bag would
decrease oxygen levels and increase CO2 further, making hypoxemia and acidosis
worse. The bicarbonate level is normal and requires no intervention. Adventitious
sounds are expected and identifying them is not the first priority
Which action is a priority for the nurse to prevent harm for a client with a pulmonary
embolism who is receiving a continuous heparin infusion?
, A. Assessing gums daily for indications of bleeding
B. Monitoring the platelet count daily
C. Assessing breath sounds
D. Comparing pedal pulses bilaterally - answerB
Daily platelet counts are a safety priority in assessing for heparin-induced
thrombocytopenia (HIT), a potential side effect of heparin.Assessing breath sounds
each shift is an important action, as is examining for indications of bleeding. However,
identifying HIT early is a greater priority so that appropriate interventions can be
initiated. Assessing bilateral pedal pulses is important if the source of the embolism is a
venous thromboembolism (VTE) in the legs; however, this is not an important general
action for a client with PE.
Which client will the nurse consider to be at the greatest risk for developing acute
respiratory distress syndrome (ARDS)?
A. A 22 year old with a fractured clavicle
B. A 39 year old with uncontrolled diabetes
C. A 56 year old with chronic kidney disease
D. A 74 year old who aspirates a tube feeding - answerD
ARDS is a type of acute respiratory failure with hypoxemia that persists even when
100% oxygen is given, decreased pulmonary compliance, dyspnea, bilateral pulmonary
edema, and dense pulmonary infiltrates on x-ray (ground-glass appearance). It often
occurs after an acute lung injury such as could result from aspiration of acidic gastric
contents. Clients who are receiving tube feedings are at particular risk for lung damage
by aspiration.Fractured clavicle, diabetes, and chronic kidney disease is associated with
an increased risk for lung injury or ARDS.
What is the primary emphasis for the nurse who is providing care to a client with acute
respiratory distress syndrome (ARDS) currently in the exudative management stage of
the disorder?
A. Assessing the client at least hourly for tachypnea and dyspnea
B. Performing meticulous mouth during mechanical ventilation
C. Assessing for abnormal lung sounds
D. Monitoring urine output to identify multiple organ dysfunction syndrome early -
answerA
The exudative phase includes early changes of dyspnea and tachypnea resulting from
the alveoli becoming fluid filled and from pulmonary shunting and atelectasis. Early
interventions focus on frequent assessment of respiratory status, supporting the client,
and providing oxygen.Abnormal lung sounds are not present at this stage because the
edema is present in the interstitial tissues and not in the airways. At this stage, clients
are neither intubated nor being mechanically ventilated. Multiple organ dysfunction
syndrome is not a feature of this stage.
