Question

Which nursing intervention is MOST appropriate for managing a patient diagnosed with a pulmonary embolism?

Answer 1

Correct Answers:

Providing supplemental oxygen to maintain adequate oxygen saturation

Rationale :

👉 A pulmonary embolism (PE) occurs when an embolus, usually a blood clot, obstructs blood flow through the pulmonary circulation.

👉 The obstruction creates a ventilation-perfusion (V/Q) mismatch, meaning areas of the lungs are ventilated but are not adequately perfused.

👉 This impairment can cause hypoxemia, dyspnea, tachypnea, chest pain, restlessness, and decreased oxygen saturation.

👉 Following the ABC priority framework, supporting breathing and oxygenation is the immediate nursing priority.

👉 Supplemental oxygen increases the amount of oxygen available for gas exchange and helps correct hypoxemia.

👉 The nurse should continuously monitor oxygen saturation, respiratory status, vital signs, level of consciousness, and signs of worsening respiratory distress.

👉 Additional treatment may include anticoagulants, thrombolytic therapy, pain management, and hemodynamic support, depending on the severity of the pulmonary embolism.

👉 Therefore, providing supplemental oxygen to maintain adequate oxygen saturation is the most appropriate nursing intervention.

❌ Administering intravenous fluids to increase blood volume

👉 IV fluids may be administered cautiously when a client with a massive PE develops hypotension or hemodynamic instability.

👉 Excessive fluid administration can increase right ventricular workload and potentially worsen cardiac function.

👉 Therefore, routine fluid administration is not the priority over correcting impaired oxygenation.

❌ Applying cold compresses to the chest to reduce pain

👉 Cold compresses do not treat the pulmonary vascular obstruction or impaired gas exchange caused by a pulmonary embolism.

👉 Chest pain associated with PE is managed by treating the underlying condition and administering prescribed analgesics when appropriate.

👉 Therefore, applying cold compresses is not an appropriate priority intervention.

❌ Encouraging ambulation to improve circulation

👉 During the acute phase of a pulmonary embolism, the client may have severe hypoxemia and cardiopulmonary instability.

👉 Activity increases oxygen demand and can worsen respiratory distress in an unstable client.

👉 The nurse should stabilize oxygenation and circulation first before encouraging activity as appropriate.

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Answer 2

Correct Answers:

Mitral valve prolapse

Rationale :

👉 Mitral valve prolapse occurs when one or both mitral valve leaflets bulge backward into the left atrium during systole.

👉 The classic auscultatory finding is a mid-systolic click, sometimes followed by a late systolic murmur.

👉 The click occurs when the abnormal valve leaflets and chordae suddenly tense during ventricular contraction.

👉 Clients may report palpitations, atypical chest pain, fatigue, anxiety, dizziness, and shortness of breath.

👉 Symptoms can occur even when there is no severe structural heart disease.

👉 Mitral valve prolapse is more commonly identified in younger and middle-aged women.

👉 The diagnosis can be confirmed through echocardiography, which shows displacement of the mitral valve leaflets into the left atrium.

👉 Therefore, the presence of a mid-systolic click with palpitations and chest discomfort strongly indicates mitral valve prolapse.

❌ Aortic stenosis

👉 Aortic stenosis usually produces a harsh systolic ejection murmur heard best at the right upper sternal border.

👉 The murmur typically radiates toward the carotid arteries.

👉 A mid-systolic click is not the characteristic finding of aortic stenosis.

❌ Mitral stenosis

👉 Mitral stenosis produces a low-pitched diastolic rumbling murmur heard best at the cardiac apex.

👉 An opening snap may be heard after the second heart sound.

👉 It does not typically cause a mid-systolic click.

❌ Tricuspid regurgitation

👉 Tricuspid regurgitation produces a holosystolic murmur heard best along the lower left sternal border.

👉 The murmur becomes louder with inspiration.

👉 A mid-systolic click is not associated with tricuspid regurgitation.

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Answer 3

Correct Answers:

Cardiac dysrhythmias

Rationale :

👉 Furosemide is a loop diuretic that increases the excretion of sodium, water, and potassium through the kidneys.

👉 A potassium level of 3.3 mEq/L indicates hypokalemia because the expected range is approximately 3.5 to 5 mEq/L.

👉 Potassium plays an essential role in maintaining normal cardiac electrical conduction.

👉 Low potassium levels increase myocardial irritability and can lead to premature ventricular contractions and other dysrhythmias.

👉 The client may develop weakness, fatigue, muscle cramps, palpitations, or an irregular pulse.

👉 Severe hypokalemia can cause dangerous ventricular dysrhythmias and may become life-threatening.

👉 The nurse should monitor the client's ECG, pulse, potassium level, and symptoms of muscle weakness.

👉 Therefore, cardiac dysrhythmias are the most important complication to monitor in a client taking furosemide with hypokalemia.

❌ Hypoglycemia

👉 Hypoglycemia is associated with excessive insulin, certain antidiabetic medications, or inadequate food intake.

👉 Furosemide does not commonly cause low blood glucose levels.

👉 The client's low potassium level is more closely associated with cardiac complications.

❌ Seizures

👉 Seizures are more commonly associated with severe sodium abnormalities, hypoglycemia, or neurological disorders.

👉 Mild hypokalemia usually affects muscles and cardiac conduction rather than directly causing seizures.

👉 Therefore, seizures are not the expected complication in this situation.

❌ Neurogenic shock

👉 Neurogenic shock typically results from a spinal cord injury that disrupts sympathetic nervous system function.

👉 It is characterized by hypotension, bradycardia, and warm, dry skin.

👉 It is not caused by furosemide-related hypokalemia.

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Answer 4

Correct Answers:

Maintain a healthy blood pressure through diet and exercise

Rationale :

👉 Maintaining a healthy blood pressure helps reduce long-term stress on the heart and blood vessels.

👉 Chronic hypertension can contribute to structural changes in the heart and accelerate cardiovascular disease.

👉 A balanced diet rich in fruits, vegetables, whole grains, and low-fat foods supports cardiovascular health.

👉 Limiting excess sodium can help prevent or control hypertension.

👉 Regular moderate exercise improves cardiac function, circulation, body weight, and blood pressure control.

👉 Managing other cardiovascular risk factors such as high cholesterol, smoking, diabetes, and obesity may also reduce valve and vascular degeneration.

👉 Although age-related calcification cannot always be prevented, controlling modifiable cardiovascular risks can lower the likelihood of disease progression.

👉 Therefore, maintaining healthy blood pressure through diet and exercise is the most appropriate lifestyle recommendation.

❌ Avoid all forms of physical activity to prevent heart strain

👉 Complete inactivity increases the risk of obesity, hypertension, poor circulation, and cardiovascular disease.

👉 Most adults benefit from regular moderate physical activity unless medically contraindicated.

👉 Avoiding all exercise does not prevent aortic stenosis.

❌ Increase daily sodium intake to strengthen heart function

👉 High sodium intake can contribute to fluid retention and elevated blood pressure.

👉 Increased blood pressure places additional strain on the cardiovascular system.

👉 Sodium intake should generally be moderated rather than increased.

❌ Engage in vigorous physical activity without medical consultation

👉 Vigorous activity may be unsafe for clients with undiagnosed or existing cardiovascular disease.

👉 Exercise intensity should be appropriate for the client's age, health status, and medical history.

👉 Moderate exercise and medical guidance are safer than unrestricted strenuous activity.

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Answer 5

Correct Answers:

83

Rationale :

👉 Formula:

gtt/min = (Volume in mL × Drop factor) ÷ Time in minutes

👉 Volume: 500 mL

👉 Drop factor: 10 gtt/mL

👉 Time: 60 min

👉 (500 × 10) ÷ 60

👉 5,000 ÷ 60 = 83.33 gtt/min

👉 Round 83.33 to the nearest whole number.

🎯 Final Answer: 83 gtt/min

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Answer 6

Correct Answers:

0.3

Rationale :

👉 Formula: mL = Desired dose ÷ Dose on hand × Quantity

👉 Desired dose: 50 mg

👉 Dose on hand: 200 mg

👉 Quantity: 1 mL

👉 50 mg ÷ 200 mg × 1 mL = 0.25 mL

👉 0.25 mL rounded to the nearest tenth = 0.3 mL

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Answer 7

Correct Answers:

Obstructive sleep apnea (OSA)

Rationale :

👉 Obstructive sleep apnea causes repeated episodes of partial or complete upper-airway obstruction during sleep.

👉 These episodes produce intermittent hypoxemia and repeated awakenings throughout the night.

👉 Hypoxemia activates the sympathetic nervous system, increasing heart rate and constricting blood vessels.

👉 Repeated sympathetic stimulation can cause persistent elevations in blood pressure, even during daytime hours.

👉 OSA is strongly associated with hypertension, particularly hypertension that is difficult to control with medication.

👉 Additional manifestations may include loud snoring, daytime sleepiness, morning headaches, and witnessed periods of apnea.

👉 Treating OSA through weight management, continuous positive airway pressure, or other prescribed therapies can help improve cardiovascular health.

👉 Therefore, obstructive sleep apnea is a recognized risk factor for developing hypertension.

❌ High-density lipoprotein level of 70 mg/dL

👉 HDL is commonly called protective or “good” cholesterol because it helps transport cholesterol away from the arteries.

👉 An HDL level of 70 mg/dL is generally considered favorable, rather than a risk factor for hypertension.

👉 Low HDL is more concerning as part of an unfavorable cardiovascular risk profile.

❌ Taking benazepril

👉 Benazepril is an angiotensin-converting enzyme inhibitor used to treat hypertension.

👉 It lowers blood pressure by reducing angiotensin II–mediated vasoconstriction and aldosterone activity.

👉 Therefore, taking benazepril is a treatment for hypertension, not a risk factor for developing it.

❌ A diet high in potassium

👉 Adequate dietary potassium can support healthy blood-pressure control by counteracting some effects of sodium.

👉 Potassium-rich foods are generally encouraged unless contraindicated by kidney disease or certain medications.

👉 Therefore, a potassium-rich diet is not considered a risk factor for hypertension.

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Answer 8

Correct Answers:

165

Rationale :

👉 Prescription: 1.5 mg/kg/dose

👉 Client’s weight: 245 lb

👉 Convert pounds to kilograms using 1 lb = 0.45 kg:

👉 245 × 0.45 = 110.25 kg

👉 Calculate the prescribed dose:

👉 1.5 mg × 110.25 kg = 165.375 mg

👉 Round 165.375 mg to the nearest whole number.

🎯 Final Answer: 165 mg per dose

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Answer 9

Correct Answers:

The client will walk for 30 min 5 days a week.

Rationale :

👉 Walking for 30 minutes on 5 days each week provides 150 minutes of moderate physical activity.

👉 This goal is specific, measurable, achievable, relevant, and time-based, making it an effective health-promotion goal.

👉 Regular aerobic exercise can help lower blood pressure and reduce cardiovascular disease risk.

👉 Physical activity can assist with weight management, which is beneficial for a client with a BMI of 26.

👉 Exercise can also improve circulation, cardiovascular endurance, mood, and cholesterol levels.

👉 The CDC recommends at least 150 minutes of moderate-intensity aerobic activity each week, such as 30 minutes on 5 days.

👉 Smoking cessation, blood-pressure control, healthy nutrition, and regular exercise should all be included in the long-term health plan.

👉 Therefore, walking for 30 minutes 5 days weekly is the most appropriate goal among the choices.

❌ The client will list foods that are high in calcium, which should be avoided.

👉 Calcium-rich foods do not generally need to be avoided for hypertension or mild overweight.

👉 Calcium is important for bone health, muscle contraction, and normal physiological function.

👉 Health teaching should focus more on limiting excessive sodium, saturated fats, and highly processed foods.

❌ The client will increase calorie intake by 200 calories per day.

👉 A BMI of 26 falls within the overweight range, so increasing calorie intake could promote additional weight gain.

👉 Weight reduction through balanced nutrition and physical activity can help improve blood-pressure control.

👉 Therefore, increasing daily calories is not an appropriate health-promotion goal.

❌ The client will replace cigarettes with smokeless tobacco products.

👉 Smokeless tobacco still exposes the client to nicotine and other harmful substances.

👉 Nicotine can increase heart rate and blood pressure and maintain tobacco dependence.

👉 The goal should be complete tobacco cessation rather than replacing cigarettes with another tobacco product.

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Answer 10

Correct Answers:

Tissue valves are less likely to cause blood clotting than mechanical valves.

Rationale :

👉 Tissue valves, also called bioprosthetic valves, are made from animal tissue or donated human tissue.

👉 Tissue valves are less thrombogenic, meaning they are less likely to promote the formation of blood clots.

👉 Because of the lower risk of thrombosis, many clients with tissue valves do not require lifelong anticoagulant therapy solely because of the valve.

👉 Mechanical valves have artificial surfaces that increase the risk of thrombus formation and systemic embolization.

👉 Clients with mechanical valves generally require lifelong anticoagulation therapy, commonly with warfarin.

👉 Avoiding lifelong anticoagulation reduces the client's risk of major bleeding complications and the burden of ongoing anticoagulation management.

👉 This advantage makes tissue valves particularly useful for clients who cannot safely take long-term anticoagulants or prefer to avoid lifelong anticoagulation.

👉 Therefore, the lower risk of blood clot formation is a key advantage of tissue valves compared with mechanical valves.

❌ Tissue valves are more durable and withstand wear and tear better than mechanical valves.

👉 Mechanical valves are more durable and can function effectively for several decades.

👉 Tissue valves gradually undergo structural deterioration and calcification.

👉 Therefore, superior durability is an advantage of mechanical valves, not tissue valves.

❌ Tissue valves are more cost-effective over the long term compared to mechanical valves.

👉 Long-term costs depend on factors such as anticoagulation monitoring, valve durability, and the possibility of repeat surgery.

👉 Tissue valves may require replacement because they have a shorter functional lifespan.

👉 Therefore, long-term cost-effectiveness is not the primary advantage of tissue valves.

❌ Tissue valves have a longer lifespan than mechanical valves.

👉 Tissue valves generally have a shorter lifespan because biological tissue deteriorates over time.

👉 Mechanical valves are designed to last for several decades and may function for the remainder of the client's life.

👉 Therefore, having a longer lifespan is an advantage of mechanical valves rather than tissue valves.

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Custom: N2100 Summer 26 Exam 2-Arceneaux

No.

1 :
Which nursing intervention is MOST appropriate for managing a patient diagnosed with a pulmonary embolism?

2 :
A 45-year-old female client presents to the clinic with complaints of palpitations, chest pain, and shortness of breath. Upon auscultation, a mid-systolic click is heard. Which of the following is the MOST likely diagnosis for this client?

3 :
A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?

4 :
A 65-year-old client with a family history of heart disease is concerned about the risk of developing aortic stenosis. Which of the following lifestyle modifications should the nurse recommend to help prevent aortic stenosis?

❌ Avoid all forms of physical activity to prevent heart strain

❌ Increase daily sodium intake to strengthen heart function

❌ Engage in vigorous physical activity without medical consultation

6 :
A nurse is preparing to administer lidocaine 50 mg IV bolus. Available is lidocaine 200 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

7 :
A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

9 :
A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?

10 :
Which of the following is a key advantage of tissue valves compared to mechanical valves in cardiac surgery?

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Custom: N2100 Summer 26 Exam 2-Arceneaux

No.

1 : Which nursing intervention is MOST appropriate for managing a patient diagnosed with a pulmonary embolism?

2 : A 45-year-old female client presents to the clinic with complaints of palpitations, chest pain, and shortness of breath. Upon auscultation, a mid-systolic click is heard. Which of the following is the MOST likely diagnosis for this client?

3 : A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?

4 : A 65-year-old client with a family history of heart disease is concerned about the risk of developing aortic stenosis. Which of the following lifestyle modifications should the nurse recommend to help prevent aortic stenosis?

❌ Avoid all forms of physical activity to prevent heart strain

❌ Increase daily sodium intake to strengthen heart function

❌ Engage in vigorous physical activity without medical consultation

6 : A nurse is preparing to administer lidocaine 50 mg IV bolus. Available is lidocaine 200 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

7 : A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

9 : A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?

10 : Which of the following is a key advantage of tissue valves compared to mechanical valves in cardiac surgery?

1 :
Which nursing intervention is MOST appropriate for managing a patient diagnosed with a pulmonary embolism?

2 :
A 45-year-old female client presents to the clinic with complaints of palpitations, chest pain, and shortness of breath. Upon auscultation, a mid-systolic click is heard. Which of the following is the MOST likely diagnosis for this client?

3 :
A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications?

4 :
A 65-year-old client with a family history of heart disease is concerned about the risk of developing aortic stenosis. Which of the following lifestyle modifications should the nurse recommend to help prevent aortic stenosis?

6 :
A nurse is preparing to administer lidocaine 50 mg IV bolus. Available is lidocaine 200 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

7 :
A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

9 :
A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?

10 :
Which of the following is a key advantage of tissue valves compared to mechanical valves in cardiac surgery?