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Which nursing assessment data support that the client has experienced a pulmonary embolism?
- A. Calf pain with dorsiflexion of the foot.
- B. Sudden onset of chest pain and dyspnea.
- C. Left-sided chest pain and diaphoresis.
- D. Bilateral crackles and low-grade fever.
Correct Answer: B
Rationale: Sudden chest pain and dyspnea (B) are classic PE symptoms from hypoxia. Calf pain (A) suggests DVT, left-sided pain (C) suggests MI, and crackles/fever (D) suggest pneumonia.
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The client is admitted to the outpatient surgery center for a bronchoscopy to rule out cancer of the lung. Which information should the nurse teach?
- A. The test will confirm the results of the MRI.
- B. The client can eat and drink immediately after the test.
- C. The HCP can do a biopsy of the tumor through the scope.
- D. There is no discomfort associated with this procedure.
Correct Answer: C
Rationale: Bronchoscopy allows biopsy (C) to diagnose lung cancer. It doesn’t confirm MRI (A), requires NPO post-procedure (B), and causes discomfort (D).
Which statement below is incorrect about a deep vein thrombosis (DVT)?
- A. Veins that are most susceptible to a deep vein thrombosis are the peroneal, posterior tibial, popliteal and superficial femoral.
- B. DVTs tend to mostly occur in the lower extremities but can occur in the upper extremities too.
- C. A deep vein thrombosis in the lower extremity has a low probability of becoming a pulmonary embolism.
- D. A DVT is a type of venous thromboembolism (VTE), which is a blood clot that starts in the vein.
Correct Answer: C
Rationale: This option is INCORRECT. All the other statements are true about a DVT. Option C is wrong because it should say: 'A deep vein thrombosis in the lower extremity has a HIGH (not low) probability of becoming a pulmonary embolism.'
What is the best way to determine whether a client with a tracheostomy is becoming hypoxemic during suctioning?
- A. Monitoring level of consciousness
- B. Assessing skin color and temperature
- C. Auscultating the respiratory rate
- D. Counting the respiratory rate
Correct Answer: C
Rationale: Auscultating the respiratory rate detects changes in breathing patterns, indicating potential hypoxemia during suctioning.
Which assessment finding noted by the nurse on the client's return to the room is an early indication that the client's oxygenation status is compromised?
- A. The client's dressing is bloody.
- B. The client appears restless.
- C. The client's heart rate is irregular.
- D. The client indicates feeling cold.
Correct Answer: B
Rationale: Restlessness is an early sign of hypoxia, indicating compromised oxygenation status, which requires immediate attention.
The nurse writes a problem of 'impaired gas exchange' for a client diagnosed with cancer of the lung. Which interventions should be included in the plan of care? Select all that apply.
- A. Apply O2 via nasal cannula.
- B. Have the dietitian plan for six (6) small meals per day.
- C. Place the client in respiratory isolation.
- D. Assess vital signs for fever.
- E. Listen to lung sounds every shift.
Correct Answer: A,D,E
Rationale: Oxygen (A), fever assessment (D), and lung sounds (E) address gas exchange in lung cancer. Small meals (B) aid nutrition, not gas exchange, and isolation (C) is unnecessary.