NUR 265 EXAM 2 SET / CORRECT QUESTIONS
& VERIFIED ANSWERS / LATEST 2026
⫸ The nurse is caring for a client who is 4 days postoperative and
suddenly develops difficulty breathing and sharp chest pain. The
nurse has called the rapid response team (RRT), raised the head of the
bed (HOB), and applied oxygen to the client. Which action(s) from
the box below should the nurse take next?
1. Auscultate the client's lung sounds.
2. Initiate continuous cardiac monitoring.
3. Prepare to administer intravenous (IV) alteplase.
4. Connect the client to a continuous pulse oximeter.
5. Apply bilateral antiembolism stockings to the legs. Answer: 1,2,4,6
⫸ The nurse has provided discharge teaching to a client who
developed a pulmonary embolism (PE) following a surgical
procedure. The client will be taking newly prescribed warfarin at
home. Which of the following client statements indicates a correct
understanding of the teaching? Answer: "I should avoid anything
rectally, such as enemas or suppositories."
⫸ The nurse is caring for a client who appears to have developed a
pulmonary embolism (PE). Which of the following arterial blood gas
(ABG) results would the nurse expect the client to initially have?
Answer: pH = 7.50;
, PaO2 = 79 mm Hg; PaCO2 = 32 mm Hg; HCO3 - = 23 mEq/L; SaO2
= 88%
⫸ The nurse is caring for the following assigned clients. The nurse
should first see the client who has Answer: received a heparin
infusion for the last 10 days and has a platelet count of 90,000
⫸ The nurse is caring for a client who has a chest tube. Which
assessment finding(s) from the box below requires the nurse to
immediately notify the primary health care provider (PHCP)? 1.
Continuous bubbling in the suction control chamber.
2. Tracheal deviation.
3. Tidaling in the water seal chamber with breathing.
4. 100 mL of drainage within an hour. 5. Visibility of the eyelets of
the chest tube.
6. Low water level in the water seal chamber. Answer: 2,4,5
⫸ The nurse is assessing a client who had a chest tube placed 36
hours ago for the treatment of a pneumothorax. The nurse observes
continuous bubbling in the water seal chamber. Which of the
following actions should the nurse take? Answer: Inform the primary
health care provider (PHCP) that there is a leak in the system.
⫸ The nurse is assessing clients for the risk of developing acute
respiratory distress syndrome (ARDS). The nurse should identify at
greatest risk the client who Answer: has sepsis and is receiving
nutrition via a continuous tube feeding
& VERIFIED ANSWERS / LATEST 2026
⫸ The nurse is caring for a client who is 4 days postoperative and
suddenly develops difficulty breathing and sharp chest pain. The
nurse has called the rapid response team (RRT), raised the head of the
bed (HOB), and applied oxygen to the client. Which action(s) from
the box below should the nurse take next?
1. Auscultate the client's lung sounds.
2. Initiate continuous cardiac monitoring.
3. Prepare to administer intravenous (IV) alteplase.
4. Connect the client to a continuous pulse oximeter.
5. Apply bilateral antiembolism stockings to the legs. Answer: 1,2,4,6
⫸ The nurse has provided discharge teaching to a client who
developed a pulmonary embolism (PE) following a surgical
procedure. The client will be taking newly prescribed warfarin at
home. Which of the following client statements indicates a correct
understanding of the teaching? Answer: "I should avoid anything
rectally, such as enemas or suppositories."
⫸ The nurse is caring for a client who appears to have developed a
pulmonary embolism (PE). Which of the following arterial blood gas
(ABG) results would the nurse expect the client to initially have?
Answer: pH = 7.50;
, PaO2 = 79 mm Hg; PaCO2 = 32 mm Hg; HCO3 - = 23 mEq/L; SaO2
= 88%
⫸ The nurse is caring for the following assigned clients. The nurse
should first see the client who has Answer: received a heparin
infusion for the last 10 days and has a platelet count of 90,000
⫸ The nurse is caring for a client who has a chest tube. Which
assessment finding(s) from the box below requires the nurse to
immediately notify the primary health care provider (PHCP)? 1.
Continuous bubbling in the suction control chamber.
2. Tracheal deviation.
3. Tidaling in the water seal chamber with breathing.
4. 100 mL of drainage within an hour. 5. Visibility of the eyelets of
the chest tube.
6. Low water level in the water seal chamber. Answer: 2,4,5
⫸ The nurse is assessing a client who had a chest tube placed 36
hours ago for the treatment of a pneumothorax. The nurse observes
continuous bubbling in the water seal chamber. Which of the
following actions should the nurse take? Answer: Inform the primary
health care provider (PHCP) that there is a leak in the system.
⫸ The nurse is assessing clients for the risk of developing acute
respiratory distress syndrome (ARDS). The nurse should identify at
greatest risk the client who Answer: has sepsis and is receiving
nutrition via a continuous tube feeding
