Quiz 2

Question 1

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to
prevent a pulmonary embolism (PE)? (SATA)

Answer 1

*Assess legs for redness
*apply elastic compression stockings
*perform passive range motion exercises

Question 2

NGN: Pulmonary embolism

Answer 2

The nurse should place the client in high-Fowler’s position and obtain venous access because
the client is most likely experiencing a pulmonary embolism (PE). Placing the client in
high-Fowler’s promotes optimal gas exchange and obtaining venous access allows for
medications to treat the PE or complications to be administered.The nurse should monitor for
petechiae on the chest and cardiac dysrhythmias, which can occur with a PE and can be life
threatening. The nurse should also monitor the client’s aPTT prior to the administration of
anticoagulants and also while the client is receiving treatment, as prescribed.

Question 3

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client
reports dyspnea and severe pain. The nurse notes that the client’s chest moves inward during inspiration and
bulges out during expiration. The nurse should identify this finding as which of the following?

Answer 3

Flail Chest

Question 4

Which symptom is of mitral valve stenosis

Answer 4

murmur/swishing or blowing sound (S4 heart sounds

Question 5

NGN: Bow tie: aortic stenosis

Answer 5

Educate: EKG every 6-12 months and decrease inflammatory response
Monitor: HR, Blood pressure

Question 6

What will you hear in the lungs with a patient with metal valve insufficiency or mitral valve regurgitation

Answer 6

crackles at the base, wet breath sounds

Question 7

A patient has had an endovascular abdominal aortic aneurysm repair. What should the RN monitor for

Answer 7

Input and output

Question 8

A patient comes in with a history of AAA and presents either severe back pain and absent pedal pulses. What should you check first?

Answer 8

Blood pressure: they are hemodynamically unstable
Monitor: increase in BP and administer beta blocker and calcium channel blocker to decrease BP and reduce the risk of ruptures

Question 9

What patient should the RN see first

Answer 9

A patient that reports sudden back or chest pain that is severe

Question 10

Modifiable to prevent AAA

Answer 10

diet
BP
smoking
drinking

Question 11

A patient is experiencing a pulmonary embolism and their BP is dropping causing hemodynamic instability. ABGs are out of range and vitals are elevated. what do we expect the provider to order

Answer 11

Alteplase
Iv
APTT
Run a pulmonary angiography

Question 12

A patient has been in a car accident. Respirations are fast and O2 is 82% what is the condition and what do you do?

Answer 12

Flail chest: intubate

Question 13

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate
of 40/min. Which of the following actions should the nurse take?

Answer 13

Adminster O2 via NC

Question 14

Sucking chest wound

Answer 14

open pneumothorax, a penetrating chest wound that creates a hole in the chest which can lead to a collapsed lun

Question 15

Flail Chest

Answer 15

Defect in the chest wall due to blunt force trauma. Unequal rise and fall of the chest

Question 16

A patient comes in with chest trauma after a motor vehicle accident. What should the nurse assess for

Answer 16

adequate chest rise and fall

Question 17

Patient has an AAA. The urine was 45 MLS with in 2-3 hrs. What labs should the nurse assess?

Answer 17

Creatinine levels to assess kidney function. (Not BUN)

Question 18

What are the treatment options for mitral valve stenosis that did not respond to medication therapy?

Answer 18

Balloon valvuloplasty: insert a small catheter through the groin and inflate a small balloon to keep the valve open

Question 19

Risk factors of AAA

Answer 19

Family history
smoking
hyperlipidemia
atherosclerosis
HTN

Question 20

A charge nurse is teaching a newly licensed nurse about deep vein thrombosis (DVT). Which of the following
should the charge nurse include as risk factors for developing DVTs?

Answer 20

Immobility
fractures
AFIB
Estrogen therapy

Question 21

A nurse is caring for a client who has deep vein thrombosis (DVT). Which of the following findings should cause
the nurse to suspect the client has a pulmonary embolism?

Answer 21

Hemoptysis
Lightheadedness
tachycardia

Question 22

A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse
should explain to the client that a murmur

Answer 22

indicates turbulent blood flow through a valve.

Question 23

A nurse is providing education to a client who has a newly diagnosed abdominal aortic aneurysm (AAA).
Which of the following statements should the nurse include in the teaching?

Answer 23

An abdominal aortic aneurysm is a dilation of the abdominal aorta greater than 30 mm in diameter.

Question 24

Where is the pain located with a AAA?

Answer 24

Severe back or groin pain

Question 25

A nurse is providing teaching to a client about manifestations of pulmonary embolism (PE). Which of the following
findings should the nurse include in the teaching? (SATA)

Answer 25

*Chest pain that worsens with deep breathing
*SOB
*Bloody sputum

Question 26

An hour 80 year old uncontrolled type 1 DM is diagnosed with aortic stenosis. When conservative therapy is no longer effective, the nurse knows that the patient will need to have what procedure?

Answer 26

Percutaneous transluminal ballon valvuloplast (PTBV)