NCLEX PULMONARY EMBOLISM EXAM
1. 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 nu
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NCLEX PULMONARY EMBOLISM EXAM
1. 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?
a. Assess the client's lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.
2. 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?
a. Encourage the client to walk 5 minutes each hour.
b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found.
3. 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?
a. Breathing so rapidly interferes with oxygenation.
b. Maybe the client has respiratory distress syndrome.
c. The blood clot interferes with perfusion in the lungs.
d. The client needs immediate intubation and mechanical ventilation.
4. 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?
a. Decrease the heparin rate.
b. Increase the heparin rate.
c. No change to the heparin rate.
d. Stop heparin; start warfarin (Coumadin).
5. 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?
a. Instruct the client to eliminate all vitamin K from the diet.
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