NUR 265/NUR265: Exam 2
Advanced Concepts in Medical-Surgical Nursing
2026-2028 Testing Cycle | Complete Guide
50 Questions With Answers & Expert Rationales.
Guaranteed Pass | Graded A+ | Galen
Q1: A client with ARDS is receiving mechanical ventilation with a PaO₂ of 58 mmHg on 80%
oxygen. The nurse recognizes that which finding best indicates refractory hypoxemia?
A. PaO₂ remains below 60 mmHg despite increasing FiO₂ to 100%
B. Bilateral crackles auscultated in all lung fields
C. Chest x-ray showing unilateral infiltrates
D. Improved oxygenation with prone positioning
Correct Answer: A
Rationale: Correct because refractory hypoxemia in ARDS is defined as a PaO₂ that remains less
than 60 mmHg despite administration of 100% oxygen, reflecting severe ventilation-perfusion
mismatch and shunting. In ARDS, the priority intervention is recognition that hypoxemia does
not improve with supplemental oxygen alone due to alveolar collapse and protein-rich fluid
filling the airspaces. The pathophysiology involves inflammatory-mediated damage to the
alveolar-capillary membrane, leading to surfactant inactivation and refractory hypoxemia that
requires mechanical ventilation with lung-protective strategies.
Q2: A nurse is caring for a postoperative client who suddenly develops dyspnea, tachycardia, and
pleuritic chest pain. Which diagnostic test does the nurse anticipate will confirm the suspected
pulmonary embolism?
A. D-dimer assay
B. Ventilation-perfusion scan
C. CT pulmonary angiography
D. Chest x-ray
,Correct Answer: C
Rationale: Correct because CT pulmonary angiography is the gold standard diagnostic test for
pulmonary embolism, providing direct visualization of filling defects within the pulmonary
arterial system. The nurse recognizes that while D-dimer is highly sensitive, it lacks specificity
and is used primarily to rule out PE rather than confirm it. In massive PE with hemodynamic
instability, the healthcare team must rapidly confirm the diagnosis to initiate emergency
anticoagulation or thrombolytic therapy.
Q3: A nurse is caring for a client receiving mechanical ventilation. Which actions are appropriate
when the high-pressure alarm sounds? (Select all that apply.)
A. Check the ventilator circuit for disconnection
B. Suction the endotracheal tube for secretions
C. Decrease the tidal volume setting
D. Remove the client from the ventilator immediately
E. Assess for signs of pneumothorax
F. Evaluate if the client is biting the endotracheal tube
Correct Answer(s): B, E, F
Rationale: Correct because suctioning removes secretions or mucus plugs that increase airway
resistance and trigger high-pressure alarms, while assessing for pneumothorax addresses
barotrauma from excessive pressure, and evaluating for tube biting identifies obstruction from
patient-induced occlusion. Checking for disconnection would address a low-pressure alarm
rather than high pressure, decreasing tidal volume is a provider intervention for lung-protective
ventilation and not an alarm response, and removing the client from the ventilator is unsafe
without first identifying the cause of the alarm. The nurse must systematically assess for the most
common causes of increased resistance before taking further action.
Q4: A nurse notes continuous bubbling in the water seal chamber of a client's three-chamber
chest tube drainage system. Which action should the nurse take first?
A. Increase the suction pressure to -30 cm H₂O
B. Milk the chest tube tubing toward the collection chamber
C. Clamp the chest tube immediately
D. Assess all tubing connections and the insertion site for an air leak
Correct Answer: D
, Rationale: Correct because continuous bubbling in the water seal chamber indicates an air leak,
and the nurse's first action is to systematically assess the entire system including tubing
connections and the insertion site to locate the source. In chest tube management, the priority
intervention is identifying whether the leak is from the patient, the tubing, or the drainage system
before taking corrective action. Expected tidaling with respiration is normal, but unexpected
continuous bubbling requires immediate assessment to prevent compromise of the water seal and
lung re-expansion.
Q5: A client with type 1 diabetes presents with blood glucose of 320 mg/dL, arterial pH of 7.25,
and positive urine ketones. Which laboratory finding does the nurse expect?
A. Serum bicarbonate greater than 22 mEq/L
B. Serum bicarbonate less than 18 mEq/L
C. Serum osmolality greater than 320 mOsm/L
D. Absent ketones in the blood
Correct Answer: B
Rationale: Correct because in diabetic ketoacidosis, metabolic acidosis drives serum bicarbonate
below 18 mEq/L as ketone bodies accumulate and buffer systems become overwhelmed. The
nurse recognizes that DKA is characterized by ketonemia, ketonuria, and acidosis requiring
insulin therapy and fluid resuscitation. A serum bicarbonate greater than 18 mEq/L, absent
ketones, and severe hyperosmolality without acidosis are hallmark findings of hyperosmolar
hyperglycemic state rather than DKA.
Q6: Which assessment findings are consistent with a client diagnosed with moderate ARDS?
(Select all that apply.)
A. PaO₂/FiO₂ ratio of 180
B. PaO₂/FiO₂ ratio of 310
C. Bilateral infiltrates on chest x-ray
D. Decreased lung compliance
E. Unilateral wheezing on auscultation
F. Normal arterial blood gas values
Correct Answer(s): A, C, D
Rationale: Correct because a PaO₂/FiO₂ ratio less than 200 meets Berlin criteria for moderate
ARDS, bilateral infiltrates represent the alveolar flooding required for diagnosis, and decreased
lung compliance results from protein-rich fluid and surfactant loss stiffening the lungs. A ratio of
Advanced Concepts in Medical-Surgical Nursing
2026-2028 Testing Cycle | Complete Guide
50 Questions With Answers & Expert Rationales.
Guaranteed Pass | Graded A+ | Galen
Q1: A client with ARDS is receiving mechanical ventilation with a PaO₂ of 58 mmHg on 80%
oxygen. The nurse recognizes that which finding best indicates refractory hypoxemia?
A. PaO₂ remains below 60 mmHg despite increasing FiO₂ to 100%
B. Bilateral crackles auscultated in all lung fields
C. Chest x-ray showing unilateral infiltrates
D. Improved oxygenation with prone positioning
Correct Answer: A
Rationale: Correct because refractory hypoxemia in ARDS is defined as a PaO₂ that remains less
than 60 mmHg despite administration of 100% oxygen, reflecting severe ventilation-perfusion
mismatch and shunting. In ARDS, the priority intervention is recognition that hypoxemia does
not improve with supplemental oxygen alone due to alveolar collapse and protein-rich fluid
filling the airspaces. The pathophysiology involves inflammatory-mediated damage to the
alveolar-capillary membrane, leading to surfactant inactivation and refractory hypoxemia that
requires mechanical ventilation with lung-protective strategies.
Q2: A nurse is caring for a postoperative client who suddenly develops dyspnea, tachycardia, and
pleuritic chest pain. Which diagnostic test does the nurse anticipate will confirm the suspected
pulmonary embolism?
A. D-dimer assay
B. Ventilation-perfusion scan
C. CT pulmonary angiography
D. Chest x-ray
,Correct Answer: C
Rationale: Correct because CT pulmonary angiography is the gold standard diagnostic test for
pulmonary embolism, providing direct visualization of filling defects within the pulmonary
arterial system. The nurse recognizes that while D-dimer is highly sensitive, it lacks specificity
and is used primarily to rule out PE rather than confirm it. In massive PE with hemodynamic
instability, the healthcare team must rapidly confirm the diagnosis to initiate emergency
anticoagulation or thrombolytic therapy.
Q3: A nurse is caring for a client receiving mechanical ventilation. Which actions are appropriate
when the high-pressure alarm sounds? (Select all that apply.)
A. Check the ventilator circuit for disconnection
B. Suction the endotracheal tube for secretions
C. Decrease the tidal volume setting
D. Remove the client from the ventilator immediately
E. Assess for signs of pneumothorax
F. Evaluate if the client is biting the endotracheal tube
Correct Answer(s): B, E, F
Rationale: Correct because suctioning removes secretions or mucus plugs that increase airway
resistance and trigger high-pressure alarms, while assessing for pneumothorax addresses
barotrauma from excessive pressure, and evaluating for tube biting identifies obstruction from
patient-induced occlusion. Checking for disconnection would address a low-pressure alarm
rather than high pressure, decreasing tidal volume is a provider intervention for lung-protective
ventilation and not an alarm response, and removing the client from the ventilator is unsafe
without first identifying the cause of the alarm. The nurse must systematically assess for the most
common causes of increased resistance before taking further action.
Q4: A nurse notes continuous bubbling in the water seal chamber of a client's three-chamber
chest tube drainage system. Which action should the nurse take first?
A. Increase the suction pressure to -30 cm H₂O
B. Milk the chest tube tubing toward the collection chamber
C. Clamp the chest tube immediately
D. Assess all tubing connections and the insertion site for an air leak
Correct Answer: D
, Rationale: Correct because continuous bubbling in the water seal chamber indicates an air leak,
and the nurse's first action is to systematically assess the entire system including tubing
connections and the insertion site to locate the source. In chest tube management, the priority
intervention is identifying whether the leak is from the patient, the tubing, or the drainage system
before taking corrective action. Expected tidaling with respiration is normal, but unexpected
continuous bubbling requires immediate assessment to prevent compromise of the water seal and
lung re-expansion.
Q5: A client with type 1 diabetes presents with blood glucose of 320 mg/dL, arterial pH of 7.25,
and positive urine ketones. Which laboratory finding does the nurse expect?
A. Serum bicarbonate greater than 22 mEq/L
B. Serum bicarbonate less than 18 mEq/L
C. Serum osmolality greater than 320 mOsm/L
D. Absent ketones in the blood
Correct Answer: B
Rationale: Correct because in diabetic ketoacidosis, metabolic acidosis drives serum bicarbonate
below 18 mEq/L as ketone bodies accumulate and buffer systems become overwhelmed. The
nurse recognizes that DKA is characterized by ketonemia, ketonuria, and acidosis requiring
insulin therapy and fluid resuscitation. A serum bicarbonate greater than 18 mEq/L, absent
ketones, and severe hyperosmolality without acidosis are hallmark findings of hyperosmolar
hyperglycemic state rather than DKA.
Q6: Which assessment findings are consistent with a client diagnosed with moderate ARDS?
(Select all that apply.)
A. PaO₂/FiO₂ ratio of 180
B. PaO₂/FiO₂ ratio of 310
C. Bilateral infiltrates on chest x-ray
D. Decreased lung compliance
E. Unilateral wheezing on auscultation
F. Normal arterial blood gas values
Correct Answer(s): A, C, D
Rationale: Correct because a PaO₂/FiO₂ ratio less than 200 meets Berlin criteria for moderate
ARDS, bilateral infiltrates represent the alveolar flooding required for diagnosis, and decreased
lung compliance results from protein-rich fluid and surfactant loss stiffening the lungs. A ratio of
