, NUR 265 Exam 2 (2 Versions) – Medical-Surgical
Nursing – Actual Questions & Answers (GCN)
100% Guarantee Pass
1. A patient with suspected pulmonary embolism arrives at the emergency
department with sudden onset shortness of breath, chest pain, and anxiety. Which
assessment finding is most consistent with a pulmonary embolism?
A. Bilateral crackles on lung auscultation
B. Pleural friction rub
C. Decreased breath sounds on one side
D. Wheezing throughout both lung fields
Answer: B — Pleural friction rub
Rationale: A pleural friction rub is a classic finding in pulmonary embolism due to
pleural inflammation. It results from the embolism causing pulmonary infarction and
irritation of the pleural surfaces. Bilateral crackles suggest heart failure or pneumonia,
decreased breath sounds suggest pneumothorax, and wheezing suggests asthma or
COPD .
2. Which ABG result would a patient who has just developed a pulmonary
embolism likely have?
A. pH 7.30, PaO₂ 70, PaCO₂ 50, HCO₃ 24, SaO₂ 85%
B. pH 7.50, PaO₂ 85, PaCO₂ 32, HCO₃ 23, SaO₂ 88%
C. pH 7.48, PaO₂ 60, PaCO₂ 48, HCO₃ 30, SaO₂ 82%
D. pH 7.25, PaO₂ 90, PaCO₂ 35, HCO₃ 18, SaO₂ 95%
Answer: B — pH 7.50, PaO₂ 85, PaCO₂ 32, HCO₃ 23, SaO₂ 88%
Rationale: Acute PE causes respiratory alkalosis due to hyperventilation from hypoxia
and anxiety. This shows elevated pH (alkalosis), decreased PaCO₂ (hypocapnia from
hyperventilation), and decreased SaO₂ (hypoxemia). The other options show respiratory
acidosis or metabolic imbalances .
,3. A patient on day 10 of heparin therapy for DVT develops blood oozing from
their Foley catheter. Which action should the nurse take first?
A. Apply pressure to the Foley site
B. Stop the heparin infusion immediately
C. Check the patient's platelet count
D. Notify the healthcare provider
Answer: C — Check the patient's platelet count
Rationale: This patient is exhibiting signs of Heparin-Induced Thrombocytopenia (HIT),
which typically occurs 5-14 days after starting heparin. HIT is characterized by platelet
destruction and paradoxical risk for DVTs and PEs. The first priority is to check platelet
count to confirm diagnosis before stopping heparin or notifying the provider .
4. A patient is discharged on warfarin for PE. Which statement by the patient
indicates clear understanding of discharge instructions?
A. "I will take aspirin with my warfarin for pain"
B. "My INR is to be monitored frequently"
C. "I can eat unlimited leafy green vegetables"
D. "I will stop warfarin if I feel better"
Answer: B — "My INR is to be monitored frequently"
Rationale: INR monitoring is essential for warfarin therapy to ensure therapeutic
anticoagulation (target INR 2-3 for PE). Aspirin increases bleeding risk, leafy greens
contain vitamin K which antagonizes warfarin, and warfarin must be taken as prescribed
regardless of symptoms .
5. A chest tube is continuously bubbling in the suction control chamber. What
should the nurse do?
A. Clamp the chest tube immediately
B. Call the doctor right away
C. No action needed – this is normal
D. Check for air leak in the system
, Answer: C — No action needed – this is normal
Rationale: Continuous bubbling in the suction control chamber is normal and indicates
the suction is working properly. Continuous bubbling in the water seal chamber would
indicate an air leak requiring intervention. The nurse should not clamp a chest tube or
call the doctor for normal findings .
6. A patient with ARDS has PaO₂ less than 55 on 100% oxygen. What is the primary
management intervention?
A. Increase PEEP gradually
B. Intubation and mechanical ventilation
C. Administer IV diuretics
D. Position in high Fowler's only
Answer: B — Intubation and mechanical ventilation
Rationale: ARDS management requires intubation and mechanical ventilation with PEEP
to maintain alveolar patency and improve oxygenation. A PaO₂ less than 55 on 100%
oxygen indicates severe hypoxemia requiring ventilatory support .
7. Which patient is at highest risk for developing ARDS?
A. Patient with mild pneumonia
B. Patient with 3rd or 4th degree burns
C. Patient with uncontrolled hypertension
D. Patient with type 2 diabetes
Answer: B — Patient with 3rd or 4th degree burns
Rationale: Severe burns (3rd or 4th degree) are a major risk factor for ARDS due to
systemic inflammatory response, fluid shifts, and potential for sepsis .
8. A patient with respiratory failure shows PaO₂ less than 60, PaCO₂ greater than
45, pH less than 7.35, and SaO₂ less than 90%. What is this indicating?
A. Respiratory alkalosis
B. Respiratory acidosis with hypoxia
Nursing – Actual Questions & Answers (GCN)
100% Guarantee Pass
1. A patient with suspected pulmonary embolism arrives at the emergency
department with sudden onset shortness of breath, chest pain, and anxiety. Which
assessment finding is most consistent with a pulmonary embolism?
A. Bilateral crackles on lung auscultation
B. Pleural friction rub
C. Decreased breath sounds on one side
D. Wheezing throughout both lung fields
Answer: B — Pleural friction rub
Rationale: A pleural friction rub is a classic finding in pulmonary embolism due to
pleural inflammation. It results from the embolism causing pulmonary infarction and
irritation of the pleural surfaces. Bilateral crackles suggest heart failure or pneumonia,
decreased breath sounds suggest pneumothorax, and wheezing suggests asthma or
COPD .
2. Which ABG result would a patient who has just developed a pulmonary
embolism likely have?
A. pH 7.30, PaO₂ 70, PaCO₂ 50, HCO₃ 24, SaO₂ 85%
B. pH 7.50, PaO₂ 85, PaCO₂ 32, HCO₃ 23, SaO₂ 88%
C. pH 7.48, PaO₂ 60, PaCO₂ 48, HCO₃ 30, SaO₂ 82%
D. pH 7.25, PaO₂ 90, PaCO₂ 35, HCO₃ 18, SaO₂ 95%
Answer: B — pH 7.50, PaO₂ 85, PaCO₂ 32, HCO₃ 23, SaO₂ 88%
Rationale: Acute PE causes respiratory alkalosis due to hyperventilation from hypoxia
and anxiety. This shows elevated pH (alkalosis), decreased PaCO₂ (hypocapnia from
hyperventilation), and decreased SaO₂ (hypoxemia). The other options show respiratory
acidosis or metabolic imbalances .
,3. A patient on day 10 of heparin therapy for DVT develops blood oozing from
their Foley catheter. Which action should the nurse take first?
A. Apply pressure to the Foley site
B. Stop the heparin infusion immediately
C. Check the patient's platelet count
D. Notify the healthcare provider
Answer: C — Check the patient's platelet count
Rationale: This patient is exhibiting signs of Heparin-Induced Thrombocytopenia (HIT),
which typically occurs 5-14 days after starting heparin. HIT is characterized by platelet
destruction and paradoxical risk for DVTs and PEs. The first priority is to check platelet
count to confirm diagnosis before stopping heparin or notifying the provider .
4. A patient is discharged on warfarin for PE. Which statement by the patient
indicates clear understanding of discharge instructions?
A. "I will take aspirin with my warfarin for pain"
B. "My INR is to be monitored frequently"
C. "I can eat unlimited leafy green vegetables"
D. "I will stop warfarin if I feel better"
Answer: B — "My INR is to be monitored frequently"
Rationale: INR monitoring is essential for warfarin therapy to ensure therapeutic
anticoagulation (target INR 2-3 for PE). Aspirin increases bleeding risk, leafy greens
contain vitamin K which antagonizes warfarin, and warfarin must be taken as prescribed
regardless of symptoms .
5. A chest tube is continuously bubbling in the suction control chamber. What
should the nurse do?
A. Clamp the chest tube immediately
B. Call the doctor right away
C. No action needed – this is normal
D. Check for air leak in the system
, Answer: C — No action needed – this is normal
Rationale: Continuous bubbling in the suction control chamber is normal and indicates
the suction is working properly. Continuous bubbling in the water seal chamber would
indicate an air leak requiring intervention. The nurse should not clamp a chest tube or
call the doctor for normal findings .
6. A patient with ARDS has PaO₂ less than 55 on 100% oxygen. What is the primary
management intervention?
A. Increase PEEP gradually
B. Intubation and mechanical ventilation
C. Administer IV diuretics
D. Position in high Fowler's only
Answer: B — Intubation and mechanical ventilation
Rationale: ARDS management requires intubation and mechanical ventilation with PEEP
to maintain alveolar patency and improve oxygenation. A PaO₂ less than 55 on 100%
oxygen indicates severe hypoxemia requiring ventilatory support .
7. Which patient is at highest risk for developing ARDS?
A. Patient with mild pneumonia
B. Patient with 3rd or 4th degree burns
C. Patient with uncontrolled hypertension
D. Patient with type 2 diabetes
Answer: B — Patient with 3rd or 4th degree burns
Rationale: Severe burns (3rd or 4th degree) are a major risk factor for ARDS due to
systemic inflammatory response, fluid shifts, and potential for sepsis .
8. A patient with respiratory failure shows PaO₂ less than 60, PaCO₂ greater than
45, pH less than 7.35, and SaO₂ less than 90%. What is this indicating?
A. Respiratory alkalosis
B. Respiratory acidosis with hypoxia
