NU 265 – Advanced Medical-Surgical Nursing / Midterm Exam
Questions, Verified Answers, and Clinical Rationales
2026/2027 Edition
Question 1
A nurse in the intensive care unit is caring for a client with severe sepsis who is
receiving mechanical ventilation. The nurse notes sudden dyspnea, asymmetric
chest expansion, absent breath sounds on the left side, and tracheal deviation to the
right. Which priority intervention should the nurse anticipate?
A. Increase the positive end-expiratory pressure (PEEP) on the ventilator.
B. Perform immediate needle decompression followed by chest tube insertion
on the left side.
C. Administer a intravenous bolus of broad-spectrum antibiotics.
D. Re-intubate the client with a larger endotracheal tube.
Correct Answer: B. Perform immediate needle decompression followed by
chest tube insertion on the left side.
Clinical Rationale: The client exhibits classic signs of a tension pneumothorax
(asymmetric chest expansion, absent breath sounds on the affected side, and
tracheal deviation away from the affected side). Emergency needle decompression
and chest tube placement are required to relieve intrapleural pressure and prevent
cardiac arrest.
Question 2
The nurse is monitoring a client who underwent a left pneumonectomy 6 hours
ago. Which positioning strategy is most appropriate for this client?
A. Position the client on the right (unoperated) side with the head elevated 30
degrees.
B. Position the client on the left (operated) side or back to promote remaining
lung expansion.
C. Place the client in Trendelenburg position to enhance venous return.
, D. Maintain the client in a completely flat supine position for the first 24 hours.
Correct Answer: B. Position the client on the left (operated) side or back to
promote remaining lung expansion.
Clinical Rationale: Following a pneumonectomy, placing the client on the
surgical side allows the remaining lung to fully expand and prevents mediastinal
shift or fluid drainage from contaminating the healthy lung.
Question 3
A client with acute respiratory distress syndrome (ARDS) is placed on mechanical
ventilation with low tidal volumes (6 mL/kg) and high PEEP. Arterial blood gas
(ABG) analysis shows: pH 7.31, PaCO2 52 mmHg, HCO3 25 mEq/L, and PaO2
78 mmHg. How should the nurse interpret these findings?
A. Severe metabolic acidosis requiring immediate bicarbonate infusion.
B. Uncompensated respiratory alkalosis causing hypoxemia.
C. Permissive hypercapnia, an expected outcome of lung-protective ventilation
strategy.
D. Ventilator failure requiring an immediate increase in tidal volume.
Correct Answer: C. Permissive hypercapnia, an expected outcome of lung-
protective ventilation strategy.
Clinical Rationale: Low tidal volume ventilation in ARDS protects against
volutrauma/barotrauma. Mild respiratory acidosis and hypercapnia (permissive
hypercapnia) are accepted trade-offs to minimize ventilator-induced lung injury,
provided pH remains > 7.20.
Question 4
The nurse assesses a client with a chest tube connected to a traditional water-seal
drainage system. Continuous, vigorous bubbling is noted in the water-seal
chamber. Which condition should the nurse suspect?
A. The client's lung has fully re-expanded.
B. Normal function of the suction control system.
, C. An air leak in the chest tube system or pleural space.
D. Obstruction of the chest tube by a blood clot.
Correct Answer: C. An air leak in the chest tube system or pleural space.
Clinical Rationale: Intermittent bubbling in the water-seal chamber during
exhalation is normal with a pneumothorax, but continuous, persistent bubbling
indicates an air leak in the tubing system or at the insertion site.
Question 5
A client with a history of deep vein thrombosis (DVT) suddenly develops dyspnea,
tachypnea, pleuritic chest pain, and a heart rate of 124 beats/min. The nurse
suspects a pulmonary embolism (PE). What is the initial diagnostic test of choice
to confirm this diagnosis in a hemodynamically stable client?
A. Computed Tomography Pulmonary Angiography (CTPA)
B. Bedside chest X-ray
C. Electrocardiogram (ECG)
D. Arterial Blood Gas (ABG) analysis
Correct Answer: A. Computed Tomography Pulmonary Angiography
(CTPA)
Clinical Rationale: CTPA is the gold standard diagnostic imaging modality for
pulmonary embolism in stable clients, providing high sensitivity and specificity for
visualizing thrombi in the pulmonary vasculature.
Question 6
The nurse is caring for a client admitted with acute exacerbation of chronic
obstructive pulmonary disease (COPD). The client is lethargic, with a respiration
rate of 8 breaths/min and PaCO2 of 68 mmHg. Which oxygen delivery device
setting should the nurse initiate initially?
A. Non-rebreather mask at 15 L/min
B. High-flow nasal cannula at 50 L/min with FiO2 0.80
, C. Venturi mask delivering a precise, low FiO2 (24%–28%)
D. Simple face mask at 10 L/min
Correct Answer: C. Venturi mask delivering a precise, low FiO2 (24%–28%)
Clinical Rationale: A Venturi mask provides precise, low-dose oxygen delivery,
which prevents suppression of the hypoxic drive in clients with chronic
hypercapnia due to severe COPD while correcting severe hypoxemia.
Question 7
A client on a medical unit is receiving continuous IV unfractionated heparin for an
acute pulmonary embolism. The nurse reviews the daily laboratory values and
notes the activated partial thromboplastin time (aPTT) is 115 seconds (control
baseline: 30 seconds). Which action should the nurse take first?
A. Increase the heparin infusion rate by 10%.
B. Stop the heparin infusion and notify the primary care provider.
C. Administer Vitamin K1 orally as prescribed.
D. Continue the current infusion rate and document the finding.
Correct Answer: B. Stop the heparin infusion and notify the primary care
provider.
Clinical Rationale: Therapeutic aPTT for heparin therapy is typically 1.5 to 2.5
times baseline (45–75 seconds). An aPTT of 115 seconds indicates excessive
anticoagulation and high bleeding risk; the infusion should be paused immediately
and protamine sulfate prepared if severe bleeding occurs.
Question 8
Which clinical manifestation observed in a client with hypovolemic shock
indicates that compensatory mechanisms are active?
A. Mean arterial pressure (MAP) drop > 20 mmHg below baseline
B. Narrowed pulse pressure with mild tachycardia and pale, cool skin
Questions, Verified Answers, and Clinical Rationales
2026/2027 Edition
Question 1
A nurse in the intensive care unit is caring for a client with severe sepsis who is
receiving mechanical ventilation. The nurse notes sudden dyspnea, asymmetric
chest expansion, absent breath sounds on the left side, and tracheal deviation to the
right. Which priority intervention should the nurse anticipate?
A. Increase the positive end-expiratory pressure (PEEP) on the ventilator.
B. Perform immediate needle decompression followed by chest tube insertion
on the left side.
C. Administer a intravenous bolus of broad-spectrum antibiotics.
D. Re-intubate the client with a larger endotracheal tube.
Correct Answer: B. Perform immediate needle decompression followed by
chest tube insertion on the left side.
Clinical Rationale: The client exhibits classic signs of a tension pneumothorax
(asymmetric chest expansion, absent breath sounds on the affected side, and
tracheal deviation away from the affected side). Emergency needle decompression
and chest tube placement are required to relieve intrapleural pressure and prevent
cardiac arrest.
Question 2
The nurse is monitoring a client who underwent a left pneumonectomy 6 hours
ago. Which positioning strategy is most appropriate for this client?
A. Position the client on the right (unoperated) side with the head elevated 30
degrees.
B. Position the client on the left (operated) side or back to promote remaining
lung expansion.
C. Place the client in Trendelenburg position to enhance venous return.
, D. Maintain the client in a completely flat supine position for the first 24 hours.
Correct Answer: B. Position the client on the left (operated) side or back to
promote remaining lung expansion.
Clinical Rationale: Following a pneumonectomy, placing the client on the
surgical side allows the remaining lung to fully expand and prevents mediastinal
shift or fluid drainage from contaminating the healthy lung.
Question 3
A client with acute respiratory distress syndrome (ARDS) is placed on mechanical
ventilation with low tidal volumes (6 mL/kg) and high PEEP. Arterial blood gas
(ABG) analysis shows: pH 7.31, PaCO2 52 mmHg, HCO3 25 mEq/L, and PaO2
78 mmHg. How should the nurse interpret these findings?
A. Severe metabolic acidosis requiring immediate bicarbonate infusion.
B. Uncompensated respiratory alkalosis causing hypoxemia.
C. Permissive hypercapnia, an expected outcome of lung-protective ventilation
strategy.
D. Ventilator failure requiring an immediate increase in tidal volume.
Correct Answer: C. Permissive hypercapnia, an expected outcome of lung-
protective ventilation strategy.
Clinical Rationale: Low tidal volume ventilation in ARDS protects against
volutrauma/barotrauma. Mild respiratory acidosis and hypercapnia (permissive
hypercapnia) are accepted trade-offs to minimize ventilator-induced lung injury,
provided pH remains > 7.20.
Question 4
The nurse assesses a client with a chest tube connected to a traditional water-seal
drainage system. Continuous, vigorous bubbling is noted in the water-seal
chamber. Which condition should the nurse suspect?
A. The client's lung has fully re-expanded.
B. Normal function of the suction control system.
, C. An air leak in the chest tube system or pleural space.
D. Obstruction of the chest tube by a blood clot.
Correct Answer: C. An air leak in the chest tube system or pleural space.
Clinical Rationale: Intermittent bubbling in the water-seal chamber during
exhalation is normal with a pneumothorax, but continuous, persistent bubbling
indicates an air leak in the tubing system or at the insertion site.
Question 5
A client with a history of deep vein thrombosis (DVT) suddenly develops dyspnea,
tachypnea, pleuritic chest pain, and a heart rate of 124 beats/min. The nurse
suspects a pulmonary embolism (PE). What is the initial diagnostic test of choice
to confirm this diagnosis in a hemodynamically stable client?
A. Computed Tomography Pulmonary Angiography (CTPA)
B. Bedside chest X-ray
C. Electrocardiogram (ECG)
D. Arterial Blood Gas (ABG) analysis
Correct Answer: A. Computed Tomography Pulmonary Angiography
(CTPA)
Clinical Rationale: CTPA is the gold standard diagnostic imaging modality for
pulmonary embolism in stable clients, providing high sensitivity and specificity for
visualizing thrombi in the pulmonary vasculature.
Question 6
The nurse is caring for a client admitted with acute exacerbation of chronic
obstructive pulmonary disease (COPD). The client is lethargic, with a respiration
rate of 8 breaths/min and PaCO2 of 68 mmHg. Which oxygen delivery device
setting should the nurse initiate initially?
A. Non-rebreather mask at 15 L/min
B. High-flow nasal cannula at 50 L/min with FiO2 0.80
, C. Venturi mask delivering a precise, low FiO2 (24%–28%)
D. Simple face mask at 10 L/min
Correct Answer: C. Venturi mask delivering a precise, low FiO2 (24%–28%)
Clinical Rationale: A Venturi mask provides precise, low-dose oxygen delivery,
which prevents suppression of the hypoxic drive in clients with chronic
hypercapnia due to severe COPD while correcting severe hypoxemia.
Question 7
A client on a medical unit is receiving continuous IV unfractionated heparin for an
acute pulmonary embolism. The nurse reviews the daily laboratory values and
notes the activated partial thromboplastin time (aPTT) is 115 seconds (control
baseline: 30 seconds). Which action should the nurse take first?
A. Increase the heparin infusion rate by 10%.
B. Stop the heparin infusion and notify the primary care provider.
C. Administer Vitamin K1 orally as prescribed.
D. Continue the current infusion rate and document the finding.
Correct Answer: B. Stop the heparin infusion and notify the primary care
provider.
Clinical Rationale: Therapeutic aPTT for heparin therapy is typically 1.5 to 2.5
times baseline (45–75 seconds). An aPTT of 115 seconds indicates excessive
anticoagulation and high bleeding risk; the infusion should be paused immediately
and protamine sulfate prepared if severe bleeding occurs.
Question 8
Which clinical manifestation observed in a client with hypovolemic shock
indicates that compensatory mechanisms are active?
A. Mean arterial pressure (MAP) drop > 20 mmHg below baseline
B. Narrowed pulse pressure with mild tachycardia and pale, cool skin
