NCLEX PULMONARY EMBOLISM EXAM 50

NCLEX PULMONARY EMBOLISM EXAM | 50

ACTUAL EXAM QUESTIONS AND 100%

CORRECT ANSWERS| GRADED A+

• A nurse answers a call light and finds a client anxious, short of breath, reporting

chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor.What action by the nurse takes priority?

• Assess the client's lung sounds.
• Notify the Rapid Response Team.
• Provide reassurance to the client.
• Take a full set of vital signs.

• A client is admitted with a pulmonary embolism (PE). The client is young, healthy,

and active and has no known risk factors for PE. What action by the nurse is most appropriate?

• Encourage the client to walk 5 minutes each hour.
• Refer the client to smoking cessation classes.
• Teach the client about factor V Leiden testing.
• Tell the client that sometimes no cause for disease is found.

• A client has a pulmonary embolism and is started on oxygen. The student nurse

asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best?

• Breathing so rapidly interferes with oxygenation.
• Maybe the client has respiratory distress syndrome.
• The blood clot interferes with perfusion in the lungs.
• The client needs immediate intubation and mechanical ventilation.

• A client is on intravenous heparin to treat a pulmonary embolism. The clients

most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? 1 / 3

• Decrease the heparin rate.
• Increase the heparin rate.
• No change to the heparin rate.
• Stop heparin; start warfarin (Coumadin).

• A client is hospitalized with a second episode of pulmonary embolism (PE).

Recent genetic testing reveals the client has an alteration in the gene CYP2C19.What action by the nurse is best?

• Instruct the client to eliminate all vitamin K from the diet.
• Prepare preoperative teaching for an inferior vena cava (IVC) filter.
• Refer the client to a chronic illness support group.
• Teach the client to use a soft-bristled toothbrush.

• A nurse is caring for four clients on intravenous heparin therapy. Which laboratory

value possibly indicates that a serious side effect has occurred?

a. Hemoglobin: 14.2 g/dL

b. Platelet count: 82,000/L

c. Red blood cell count: 4.8/mm3

d. White blood cell count: 8.7/mm3

• What is a NORMAL platelet count value?

150,000 - 450,000

• A client appears dyspneic, but the oxygen saturation is 97%. What action by the

nurse is best?

• Assess for other manifestations of hypoxia.
• Change the sensor on the pulse oximeter.
• Obtain a new oximeter from central supply.
• Tell the client to take slow, deep breaths. 2 / 3

• A nurse is assisting the health care provider who is intubating a client. The

provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority?

• Ensure the client has adequate sedation.
• Find another provider to intubate.
• Interrupt the procedure to give oxygen.
• Monitor the clients oxygen saturation.

• An intubated client's oxygen saturation has dropped to 88%. What action by the

nurse takes priority?

• Determine if the tube is kinked.
• Ensure all connections are patent.
• Listen to the clients lung sounds.
• Suction the endotracheal tube.

• A client is on a ventilator and is sedated. What care may the nurse delegate to the

unlicensed assistive personnel (UAP)?

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