, NUR 265 Exam 2 (2 Versions) – Medical-Surgical
Nursing –Actual Questions & Answers (GCN)
100% Guarantee Pass
Version 1
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) Cough
• C) Lower extremity edema
• D) Productive cough with yellow sputum
Correct Answer: B) Cough
Rationale: A cough, often dry or with minimal sputum, is a common symptom of a PE
due to irritation or infarction of pulmonary tissues. Tachycardia, not bradycardia, is more
typical. Lower extremity edema is a sign of a deep vein thrombosis (DVT), which is a risk
factor for a PE but not a direct finding .
2. A client on a mechanical ventilator has a high-pressure alarm sounding. What is
the nurse's priority action?
• A) Suction the client immediately
• B) Silence the alarm and troubleshoot
• C) Assess the client and call for help
• D) Increase the PEEP setting
Correct Answer: C) Assess the client and call for help
Rationale: The priority is to assess the patient, not the monitor. Common causes of a
high-pressure alarm include a blocked airway from secretions, coughing, a kink in the
tubing, or a tension pneumothorax. If the patient is in respiratory distress, the nurse
should call for help, disconnect the ventilator, and start bagging .
,3. The nurse is caring for a client who is 4 days post-operative and suddenly
develops difficulty breathing and sharp chest pain. After calling the Rapid
Response Team and applying oxygen, which actions should the nurse take next?
•
1. Auscultate the client's lung sounds.
•
2. Initiate continuous cardiac monitoring.
•
3. Connect the client to a continuous pulse oximeter.
• A) 1 only
• B) 2 only
• C) 3 only
• D) 1, 2, and 3
Correct Answer: D) 1, 2, and 3
Rationale: All three actions are appropriate and should be initiated simultaneously to
assess the client's respiratory and cardiac status. These interventions provide critical
baseline data to guide further treatment for a suspected PE .
4. The nurse has provided discharge teaching to a client who developed a 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?
• A) "Hard candy can be used if I develop a dry mouth while taking warfarin."
• B) "The warfarin will continue to break up the clot over the next several months."
• C) "I should avoid anything rectally, such as enemas or suppositories."
• D) "I will take this medication for about 1-2 months."
Correct Answer: C) "I should avoid anything rectally, such as enemas or
suppositories."
, Rationale: Warfarin is an anticoagulant that increases the risk of bleeding. Rectal
procedures and enemas can cause trauma and bleeding and should be avoided.
Warfarin does not break up a clot; it prevents new clots from forming. It is often taken
for 3-6 months or longer .
5. Which arterial blood gas (ABG) result would the nurse initially expect in a client
experiencing a pulmonary embolism?
• A) pH 7.31, PaO2 73 mm Hg, PaCO2 50 mm Hg, HCO3 22 mEq/L, SaO2 85%
• B) pH 7.50, PaO2 79 mm Hg, PaCO2 32 mm Hg, HCO3 23 mEq/L, SaO2 88%
• C) pH 7.35, PaO2 63 mm Hg, PaCO2 42 mm Hg, HCO3 26 mEq/L, SaO2 84%
• D) pH 7.45, PaO2 70 mm Hg, PaCO2 38 mm Hg, HCO3 28 mEq/L, SaO2 86%
Correct Answer: B) pH 7.50, PaO2 79 mm Hg, PaCO2 32 mm Hg, HCO3 23 mEq/L,
SaO2 88%
Rationale: An early PE often results in respiratory alkalosis due to hyperventilation (low
PaCO2), leading to a high pH (alkalemia), mild hypoxemia (low PaO2), and a decreased
SaO2 due to ventilation-perfusion mismatch .
6. A client is diagnosed with Acute Respiratory Distress Syndrome (ARDS). Which
intervention is most appropriate for this client?
• A) Prone positioning
• B) High tidal volume ventilation
• C) Rapid weaning from the ventilator
• D) Suctioning every 30 minutes
Correct Answer: A) Prone positioning
Rationale: Prone positioning improves ventilation-perfusion matching, which can be
severely compromised in ARDS. High tidal volumes can cause ventilator-induced lung
injury. Suctioning is performed as needed, not on a fixed schedule .
7. A client on a ventilator has a PaCO2 of 58 mmHg. Which ventilator adjustment
might the provider order?
• A) Increase PEEP
Nursing –Actual Questions & Answers (GCN)
100% Guarantee Pass
Version 1
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) Cough
• C) Lower extremity edema
• D) Productive cough with yellow sputum
Correct Answer: B) Cough
Rationale: A cough, often dry or with minimal sputum, is a common symptom of a PE
due to irritation or infarction of pulmonary tissues. Tachycardia, not bradycardia, is more
typical. Lower extremity edema is a sign of a deep vein thrombosis (DVT), which is a risk
factor for a PE but not a direct finding .
2. A client on a mechanical ventilator has a high-pressure alarm sounding. What is
the nurse's priority action?
• A) Suction the client immediately
• B) Silence the alarm and troubleshoot
• C) Assess the client and call for help
• D) Increase the PEEP setting
Correct Answer: C) Assess the client and call for help
Rationale: The priority is to assess the patient, not the monitor. Common causes of a
high-pressure alarm include a blocked airway from secretions, coughing, a kink in the
tubing, or a tension pneumothorax. If the patient is in respiratory distress, the nurse
should call for help, disconnect the ventilator, and start bagging .
,3. The nurse is caring for a client who is 4 days post-operative and suddenly
develops difficulty breathing and sharp chest pain. After calling the Rapid
Response Team and applying oxygen, which actions should the nurse take next?
•
1. Auscultate the client's lung sounds.
•
2. Initiate continuous cardiac monitoring.
•
3. Connect the client to a continuous pulse oximeter.
• A) 1 only
• B) 2 only
• C) 3 only
• D) 1, 2, and 3
Correct Answer: D) 1, 2, and 3
Rationale: All three actions are appropriate and should be initiated simultaneously to
assess the client's respiratory and cardiac status. These interventions provide critical
baseline data to guide further treatment for a suspected PE .
4. The nurse has provided discharge teaching to a client who developed a 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?
• A) "Hard candy can be used if I develop a dry mouth while taking warfarin."
• B) "The warfarin will continue to break up the clot over the next several months."
• C) "I should avoid anything rectally, such as enemas or suppositories."
• D) "I will take this medication for about 1-2 months."
Correct Answer: C) "I should avoid anything rectally, such as enemas or
suppositories."
, Rationale: Warfarin is an anticoagulant that increases the risk of bleeding. Rectal
procedures and enemas can cause trauma and bleeding and should be avoided.
Warfarin does not break up a clot; it prevents new clots from forming. It is often taken
for 3-6 months or longer .
5. Which arterial blood gas (ABG) result would the nurse initially expect in a client
experiencing a pulmonary embolism?
• A) pH 7.31, PaO2 73 mm Hg, PaCO2 50 mm Hg, HCO3 22 mEq/L, SaO2 85%
• B) pH 7.50, PaO2 79 mm Hg, PaCO2 32 mm Hg, HCO3 23 mEq/L, SaO2 88%
• C) pH 7.35, PaO2 63 mm Hg, PaCO2 42 mm Hg, HCO3 26 mEq/L, SaO2 84%
• D) pH 7.45, PaO2 70 mm Hg, PaCO2 38 mm Hg, HCO3 28 mEq/L, SaO2 86%
Correct Answer: B) pH 7.50, PaO2 79 mm Hg, PaCO2 32 mm Hg, HCO3 23 mEq/L,
SaO2 88%
Rationale: An early PE often results in respiratory alkalosis due to hyperventilation (low
PaCO2), leading to a high pH (alkalemia), mild hypoxemia (low PaO2), and a decreased
SaO2 due to ventilation-perfusion mismatch .
6. A client is diagnosed with Acute Respiratory Distress Syndrome (ARDS). Which
intervention is most appropriate for this client?
• A) Prone positioning
• B) High tidal volume ventilation
• C) Rapid weaning from the ventilator
• D) Suctioning every 30 minutes
Correct Answer: A) Prone positioning
Rationale: Prone positioning improves ventilation-perfusion matching, which can be
severely compromised in ARDS. High tidal volumes can cause ventilator-induced lung
injury. Suctioning is performed as needed, not on a fixed schedule .
7. A client on a ventilator has a PaCO2 of 58 mmHg. Which ventilator adjustment
might the provider order?
• A) Increase PEEP
