NUR 265 Exam 2| Questions and Answers |
2026 Update | 100% Correct - Galen
College of Nursing.
PART 1: RESPIRATORY DISORDERS
PE, ARDS, Chest Tubes, ABGs, Mechanical Ventilation
Q1. The nurse is caring for a client receiving a heparin infusion for
treatment of a pulmonary embolism (PE). Which laboratory finding
indicates a therapeutic effect of treatment?
A) Activated partial thromboplastin time (aPTT) of 72 seconds
B) Platelet count of 160,000/mm³
C) Prothrombin time (PT) of 10.2 seconds
D) D-dimer level increased to 600 ng/mL
Correct ,,,,answer,,,: A
Rationale: Therapeutic aPTT for heparin is 1.5–2.5 times the normal
control (approx 60–70 seconds). An aPTT of 72 seconds indicates
adequate anticoagulation .
Q2. The nurse assesses a client with a suspected pulmonary embolism
(PE). Which assessment finding is classic for this condition?
A) Bradycardia and hypothermia
B) Pleural friction rub
C) Clear lung sounds bilaterally
D) Hypertension unresponsive to fluids
Correct ,,,,answer,,,: B
Rationale: A pleural friction rub (scratching sound heard during
,inspiration/expiration) is a classic sign of pulmonary embolism caused by
pleural inflammation. Hypoxia drives most symptoms: dyspnea, chest
pain, apprehension, and tachypnea .
Q3. A client 4 days post-operative suddenly develops difficulty
breathing and sharp chest pain. The nurse has called the rapid
response team, raised the head of the bed, and applied oxygen. Which
action should the nurse take next?
A) Auscultate the client's lung sounds
B) Initiate continuous cardiac monitoring
C) Prepare to administer IV alteplase (tPA)
D) Assess the client's skin color
Correct ,,,,answer,,,: B
Rationale: After initial interventions (O2, HOB up, call RRT), continuous
cardiac monitoring is the priority. Monitor for tachycardia, dysrhythmias,
and right heart strain patterns .
Q4. The nurse has provided discharge instructions to a client who
developed a pulmonary embolism following surgery and will be taking
warfarin at home. Which client statement indicates correct
understanding?
A) "I will take this medication for about 1–2 months."
B) "Hard candy can be used if I develop a dry mouth."
C) "The warfarin will continue to break up clots over the next several
months."
D) "I should avoid anything rectally such as enemas or suppositories."
Correct ,,,,answer,,,: D
Rationale: Warfarin increases bleeding risk. Clients should avoid rectal
suppositories, enemas, and rectal temperature measurements to prevent
mucosal trauma and bleeding. INR requires frequent monitoring .
,Q5. The arterial blood gas (ABG) results for a client with a newly
developed pulmonary embolism show: pH 7.60, PaO2 85 mm Hg,
PaCO2 32 mm Hg, HCO3 23 mEq/L, SaO2 88%. Which acid-base
imbalance does the nurse recognize?
A) Metabolic alkalosis
B) Metabolic acidosis
C) Respiratory alkalosis
D) Respiratory acidosis
Correct ,,,,answer,,,: C
Rationale: In acute PE, hyperventilation causes respiratory alkalosis (high
pH >7.45, low PaCO2 <35). As hypoxemia worsens, the client may
progress to respiratory acidosis .
Q6. The nurse is caring for four clients. Which client requires
immediate assessment first?
A) A client on day 2 of heparin therapy with a platelet count of 180,000
B) A client on day 10 of heparin therapy with blood oozing from the Foley
catheter
C) A client on warfarin with an INR of 2.5
D) A client post-PE with an aPTT of 68 seconds
Correct ,,,,answer,,,: B
*Rationale: Bleeding from the urinary catheter on day 10 of heparin may
indicate heparin-induced thrombocytopenia (HIT) or excessive
anticoagulation. This requires immediate intervention and provider
notification .*
Q7. The nurse observes continuous bubbling in the water seal chamber
of a chest tube drainage system for a client who is 4 days post-
operative. What is the nurse's best action?
A) Document the finding as normal
, B) Clamp the chest tube immediately
C) Call the provider to report a possible air leak
D) Increase suction pressure to stop bubbling
Correct ,,,,answer,,,: C
Rationale: Continuous bubbling in the water seal chamber indicates an air
leak in the system. The nurse should assess for source of leak and notify
the provider. Bubbling in the suction control chamber is normal .
Q8. The nurse assesses a client with a chest tube and notes
asymmetrical chest expansion. Which action should the nurse take?
A) Document the finding and continue monitoring
B) Notify the provider immediately
C) Milk the chest tube to promote drainage
D) Clamp the chest tube for transport to x-ray
Correct ,,,,answer,,,: B
Rationale: Asymmetrical chest expansion in a client with a chest tube may
indicate a pneumothorax, tube displacement, or blockage. This requires
immediate provider notification .
Q9. The nurse notes that the chest tube drainage collection chamber
has 120 mL of drainage in the past hour. What is the priority action?
A) Document normal post-operative drainage
B) Clamp the chest tube and notify the provider
C) Assess vital signs and notify the provider
D) Increase IV fluid rate to maintain volume
Correct ,,,,answer,,,: C
*Rationale: Drainage of >100 mL/hr suggests active bleeding. Assess vital
signs for hypovolemia and notify the provider immediately. A chest X-ray is
also indicated .*
2026 Update | 100% Correct - Galen
College of Nursing.
PART 1: RESPIRATORY DISORDERS
PE, ARDS, Chest Tubes, ABGs, Mechanical Ventilation
Q1. The nurse is caring for a client receiving a heparin infusion for
treatment of a pulmonary embolism (PE). Which laboratory finding
indicates a therapeutic effect of treatment?
A) Activated partial thromboplastin time (aPTT) of 72 seconds
B) Platelet count of 160,000/mm³
C) Prothrombin time (PT) of 10.2 seconds
D) D-dimer level increased to 600 ng/mL
Correct ,,,,answer,,,: A
Rationale: Therapeutic aPTT for heparin is 1.5–2.5 times the normal
control (approx 60–70 seconds). An aPTT of 72 seconds indicates
adequate anticoagulation .
Q2. The nurse assesses a client with a suspected pulmonary embolism
(PE). Which assessment finding is classic for this condition?
A) Bradycardia and hypothermia
B) Pleural friction rub
C) Clear lung sounds bilaterally
D) Hypertension unresponsive to fluids
Correct ,,,,answer,,,: B
Rationale: A pleural friction rub (scratching sound heard during
,inspiration/expiration) is a classic sign of pulmonary embolism caused by
pleural inflammation. Hypoxia drives most symptoms: dyspnea, chest
pain, apprehension, and tachypnea .
Q3. A client 4 days post-operative suddenly develops difficulty
breathing and sharp chest pain. The nurse has called the rapid
response team, raised the head of the bed, and applied oxygen. Which
action should the nurse take next?
A) Auscultate the client's lung sounds
B) Initiate continuous cardiac monitoring
C) Prepare to administer IV alteplase (tPA)
D) Assess the client's skin color
Correct ,,,,answer,,,: B
Rationale: After initial interventions (O2, HOB up, call RRT), continuous
cardiac monitoring is the priority. Monitor for tachycardia, dysrhythmias,
and right heart strain patterns .
Q4. The nurse has provided discharge instructions to a client who
developed a pulmonary embolism following surgery and will be taking
warfarin at home. Which client statement indicates correct
understanding?
A) "I will take this medication for about 1–2 months."
B) "Hard candy can be used if I develop a dry mouth."
C) "The warfarin will continue to break up clots over the next several
months."
D) "I should avoid anything rectally such as enemas or suppositories."
Correct ,,,,answer,,,: D
Rationale: Warfarin increases bleeding risk. Clients should avoid rectal
suppositories, enemas, and rectal temperature measurements to prevent
mucosal trauma and bleeding. INR requires frequent monitoring .
,Q5. The arterial blood gas (ABG) results for a client with a newly
developed pulmonary embolism show: pH 7.60, PaO2 85 mm Hg,
PaCO2 32 mm Hg, HCO3 23 mEq/L, SaO2 88%. Which acid-base
imbalance does the nurse recognize?
A) Metabolic alkalosis
B) Metabolic acidosis
C) Respiratory alkalosis
D) Respiratory acidosis
Correct ,,,,answer,,,: C
Rationale: In acute PE, hyperventilation causes respiratory alkalosis (high
pH >7.45, low PaCO2 <35). As hypoxemia worsens, the client may
progress to respiratory acidosis .
Q6. The nurse is caring for four clients. Which client requires
immediate assessment first?
A) A client on day 2 of heparin therapy with a platelet count of 180,000
B) A client on day 10 of heparin therapy with blood oozing from the Foley
catheter
C) A client on warfarin with an INR of 2.5
D) A client post-PE with an aPTT of 68 seconds
Correct ,,,,answer,,,: B
*Rationale: Bleeding from the urinary catheter on day 10 of heparin may
indicate heparin-induced thrombocytopenia (HIT) or excessive
anticoagulation. This requires immediate intervention and provider
notification .*
Q7. The nurse observes continuous bubbling in the water seal chamber
of a chest tube drainage system for a client who is 4 days post-
operative. What is the nurse's best action?
A) Document the finding as normal
, B) Clamp the chest tube immediately
C) Call the provider to report a possible air leak
D) Increase suction pressure to stop bubbling
Correct ,,,,answer,,,: C
Rationale: Continuous bubbling in the water seal chamber indicates an air
leak in the system. The nurse should assess for source of leak and notify
the provider. Bubbling in the suction control chamber is normal .
Q8. The nurse assesses a client with a chest tube and notes
asymmetrical chest expansion. Which action should the nurse take?
A) Document the finding and continue monitoring
B) Notify the provider immediately
C) Milk the chest tube to promote drainage
D) Clamp the chest tube for transport to x-ray
Correct ,,,,answer,,,: B
Rationale: Asymmetrical chest expansion in a client with a chest tube may
indicate a pneumothorax, tube displacement, or blockage. This requires
immediate provider notification .
Q9. The nurse notes that the chest tube drainage collection chamber
has 120 mL of drainage in the past hour. What is the priority action?
A) Document normal post-operative drainage
B) Clamp the chest tube and notify the provider
C) Assess vital signs and notify the provider
D) Increase IV fluid rate to maintain volume
Correct ,,,,answer,,,: C
*Rationale: Drainage of >100 mL/hr suggests active bleeding. Assess vital
signs for hypovolemia and notify the provider immediately. A chest X-ray is
also indicated .*
