,NUR265/NUR 265 Exam 2 | Medical-Surgical
Nursing | Galen College | Q & A | 2026/2027
Edition (PDF)
**1. The nurse is assessing a client who is suspected of having a pulmonary embolism (PE). Which of the
following findings is consistent with this diagnosis?**
A) Bradycardia
B) Productive cough with yellow sputum
C) Cough
D) Lower extremity edema
Correct Answer: C) Cough
Rationale: A cough, often dry or with minimal sputum, is a common symptom of PE due to irritation or
infarction of the pulmonary tissues. Other common signs include sudden onset dyspnea and pleuritic
chest pain. Bradycardia is uncommon; tachycardia is more typical. Lower extremity edema may be a sign
of deep vein thrombosis (DVT) but not a direct finding of PE.
**2. 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 should the nurse take next?**
A) Auscultate the client's lung sounds
B) Administer morphine for pain
C) Prepare for intubation
D) Obtain a STAT chest x-ray
Correct Answer: A) Auscultate the client's lung sounds
Rationale: After initiating immediate life-saving measures (oxygen, HOB elevation, and calling RRT), the
nurse should auscultate lung sounds to assess for changes such as diminished breath sounds, crackles,
or wheezes. This assessment guides further interventions and helps differentiate between PE,
pneumothorax, or other causes of acute respiratory distress.
,**3. The nurse is assessing a client who had a chest tube placed 36 hours ago for pneumothorax. The
nurse observes continuous bubbling in the water seal chamber. Which action should the nurse take?**
A) Clamp the chest tube immediately
B) Inform the primary health care provider that there is a leak in the system
C) Milk the chest tube to clear any clots
D) Increase suction to stop the bubbling
Correct Answer: B) Inform the primary health care provider that there is a leak in the system
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system. The nurse
should assess the system for external leaks and notify the healthcare provider. Clamping the chest tube
is not recommended as it can lead to tension pneumothorax. Intermittent bubbling is expected with
expiration.
**4. The perioperative nurse needs to monitor the patient for hallucinations and agitation when which
anesthetic agent is administered?**
A) Ketamine
B) Halothane
C) Thiopental
D) Nitrous oxide
Correct Answer: A) Ketamine
Rationale: Ketamine is a dissociative anesthetic associated with a risk of agitation, hallucinations, and
nightmares. Anticipate use of a benzodiazepine if agitation and hallucinations occur. A calm, quiet
environment is essential in postoperative care. These unwanted effects are not associated with
thiopental, halothane, or nitrous oxide.
**5. The circulating nurse is caring for a patient during a colon resection. What observation made by the
nurse is immediately recognized as a violation of aseptic technique?**
A) A glove contacts the leg of the table that supports the sterile field
, B) The cuff of the scrub nurse's sterile gown contacts the sterile field
C) The sterile field was established at 0650, and the current time is 0900
D) A contaminated item is removed from the field and the area is marked off
Correct Answer: A) A glove contacts the leg of the table that supports the sterile field
Rationale: Tables are sterile only at tabletop level. Areas below this are considered contaminated. The
sterile gown below the point 2 inches above the elbow is considered sterile. The passage of time in and
of itself does not necessarily render a field contaminated. If the unsterile item is small (e.g., unopened
suture), once it is removed, the area is marked off and a wide margin is maintained.
**6. A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive
regional anesthesia during the procedure. As the patient is prepared in the operating room, what action
would the nurse implement to maintain patient safety related to regional anesthesia?**
A) Apply grounding pad to unaffected leg
B) Assess peripheral pulses and skin color
C) Verify the last oral intake before surgery
D) Ensure a smooth surface under the patient
Correct Answer: C) Verify the last oral intake before surgery
Rationale: Regional anesthesia decreases sensation to the anesthetized area without impairing level of
consciousness, which means the affected leg will be without sensation while the anesthetic is effective.
A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient's risk of
impaired skin integrity because the patient does not have sensation and cannot identify discomfort or
foreign objects and will not be moving during surgery. The nurse's role includes positioning the patient
for correct alignment, exposure of the surgical site, and preventing injury. The other options will be
occurring but are not directly related to the regional anesthesia.
**7. Which intraoperative nursing responsibilities are performed by the scrub nurse? (Select all that
apply.)**
A) Documenting intraoperative care
B) Keeping track of irrigation solutions for monitoring of blood loss
Nursing | Galen College | Q & A | 2026/2027
Edition (PDF)
**1. The nurse is assessing a client who is suspected of having a pulmonary embolism (PE). Which of the
following findings is consistent with this diagnosis?**
A) Bradycardia
B) Productive cough with yellow sputum
C) Cough
D) Lower extremity edema
Correct Answer: C) Cough
Rationale: A cough, often dry or with minimal sputum, is a common symptom of PE due to irritation or
infarction of the pulmonary tissues. Other common signs include sudden onset dyspnea and pleuritic
chest pain. Bradycardia is uncommon; tachycardia is more typical. Lower extremity edema may be a sign
of deep vein thrombosis (DVT) but not a direct finding of PE.
**2. 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 should the nurse take next?**
A) Auscultate the client's lung sounds
B) Administer morphine for pain
C) Prepare for intubation
D) Obtain a STAT chest x-ray
Correct Answer: A) Auscultate the client's lung sounds
Rationale: After initiating immediate life-saving measures (oxygen, HOB elevation, and calling RRT), the
nurse should auscultate lung sounds to assess for changes such as diminished breath sounds, crackles,
or wheezes. This assessment guides further interventions and helps differentiate between PE,
pneumothorax, or other causes of acute respiratory distress.
,**3. The nurse is assessing a client who had a chest tube placed 36 hours ago for pneumothorax. The
nurse observes continuous bubbling in the water seal chamber. Which action should the nurse take?**
A) Clamp the chest tube immediately
B) Inform the primary health care provider that there is a leak in the system
C) Milk the chest tube to clear any clots
D) Increase suction to stop the bubbling
Correct Answer: B) Inform the primary health care provider that there is a leak in the system
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the system. The nurse
should assess the system for external leaks and notify the healthcare provider. Clamping the chest tube
is not recommended as it can lead to tension pneumothorax. Intermittent bubbling is expected with
expiration.
**4. The perioperative nurse needs to monitor the patient for hallucinations and agitation when which
anesthetic agent is administered?**
A) Ketamine
B) Halothane
C) Thiopental
D) Nitrous oxide
Correct Answer: A) Ketamine
Rationale: Ketamine is a dissociative anesthetic associated with a risk of agitation, hallucinations, and
nightmares. Anticipate use of a benzodiazepine if agitation and hallucinations occur. A calm, quiet
environment is essential in postoperative care. These unwanted effects are not associated with
thiopental, halothane, or nitrous oxide.
**5. The circulating nurse is caring for a patient during a colon resection. What observation made by the
nurse is immediately recognized as a violation of aseptic technique?**
A) A glove contacts the leg of the table that supports the sterile field
, B) The cuff of the scrub nurse's sterile gown contacts the sterile field
C) The sterile field was established at 0650, and the current time is 0900
D) A contaminated item is removed from the field and the area is marked off
Correct Answer: A) A glove contacts the leg of the table that supports the sterile field
Rationale: Tables are sterile only at tabletop level. Areas below this are considered contaminated. The
sterile gown below the point 2 inches above the elbow is considered sterile. The passage of time in and
of itself does not necessarily render a field contaminated. If the unsterile item is small (e.g., unopened
suture), once it is removed, the area is marked off and a wide margin is maintained.
**6. A patient having an open reduction internal fixation (ORIF) of a left lower leg fracture will receive
regional anesthesia during the procedure. As the patient is prepared in the operating room, what action
would the nurse implement to maintain patient safety related to regional anesthesia?**
A) Apply grounding pad to unaffected leg
B) Assess peripheral pulses and skin color
C) Verify the last oral intake before surgery
D) Ensure a smooth surface under the patient
Correct Answer: C) Verify the last oral intake before surgery
Rationale: Regional anesthesia decreases sensation to the anesthetized area without impairing level of
consciousness, which means the affected leg will be without sensation while the anesthetic is effective.
A double tourniquet on the affected leg is used to restrict blood flow. This increases the patient's risk of
impaired skin integrity because the patient does not have sensation and cannot identify discomfort or
foreign objects and will not be moving during surgery. The nurse's role includes positioning the patient
for correct alignment, exposure of the surgical site, and preventing injury. The other options will be
occurring but are not directly related to the regional anesthesia.
**7. Which intraoperative nursing responsibilities are performed by the scrub nurse? (Select all that
apply.)**
A) Documenting intraoperative care
B) Keeping track of irrigation solutions for monitoring of blood loss
