ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 32 Questions
Question 1 of 5
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. What action by the nurse is best?
Correct Answer: C
Rationale: The client's symptoms of anxiety, shortness of breath, chest pain, and hypotension suggest a pulmonary embolism, which can significantly impair gas exchange. Thrombolytic therapy is indicated for a large pulmonary embolism causing hemodynamic instability, as it can dissolve the clot and restore oxygenation.
Question 2 of 5
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
Correct Answer: B
Rationale: A PTT of 25 seconds is below the therapeutic range (typically 1.5"?2.5 times the control value of ~30 seconds), indicating insufficient anticoagulation. Increasing the heparin rate is necessary to achieve therapeutic levels and effectively treat the pulmonary embolism.
Question 3 of 5
A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred?
Correct Answer: B
Rationale: A platelet count of 82,000/µL is low and may indicate heparin-induced thrombocytopenia (HIT), a serious side effect of heparin therapy. The other laboratory values are within normal ranges and do not suggest a serious adverse effect.
Question 4 of 5
A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
Correct Answer: A
Rationale: Pulse oximetry can sometimes produce normal readings despite hypoxia due to factors like poor peripheral perfusion. A thorough assessment for other signs of hypoxia (e.g., tachycardia, confusion) is the most appropriate action to confirm the client's status.
Question 5 of 5
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?
Correct Answer: C
Rationale: Intubation attempts should not exceed 30 seconds to prevent hypoxia. Interrupting the procedure to provide oxygen is the priority to ensure the client's safety.