West Coast University NURS 480 – Exam 1 questions verified
with correct answers plus rationales 2026/2027 version
1. A client has a chest tube connected to a water-seal drainage system. Which finding
indicates that the client's lung has likely re-expanded?
A. Continuous bubbling in the water-seal chamber
B. Absence of expected tidaling in the water-seal chamber when the lung has re-expanded
C. Increasing subcutaneous emphysema
D. Sudden severe dyspnea
Answer: B. Absence of expected tidaling in the water-seal chamber when the lung has re-
expanded
Rationale: Tidaling can cease when the lung has fully re-expanded, although the nurse should
also assess the entire system and the client's respiratory status.
2. A client with a chest tube has continuous bubbling in the water-seal chamber. What
should the nurse suspect?
A. Normal lung re-expansion
B. An air leak
C. Fluid overload
D. Pulmonary edema
Answer: B. An air leak
Rationale: Continuous bubbling in the water-seal chamber generally indicates an air leak
somewhere in the system.
3. A client has just returned from a bronchoscopy. Which nursing action is appropriate?
A. Offer oral fluids immediately
B. Encourage solid food
C. Withhold oral intake until the gag reflex returns
D. Place the client in Trendelenburg position
Answer: C. Withhold oral intake until the gag reflex returns
Rationale: Local anesthesia used during bronchoscopy can temporarily impair the gag reflex,
increasing aspiration risk.
,4. A client develops a pulmonary embolism. Which medication should the nurse anticipate?
A. Furosemide
B. Atropine
C. Heparin
D. Acetaminophen
Answer: C. Heparin
Rationale: Anticoagulation is commonly initiated to prevent further clot formation and
embolization when clinically appropriate.
5. A client with ARDS has inadequate surfactant production. Which consequence should
the nurse expect?
A. Increased alveolar stability
B. Increased lung compliance
C. Alveolar collapse and decreased lung compliance
D. Increased oxygen diffusion
Answer: C. Alveolar collapse and decreased lung compliance
Rationale: Surfactant reduces surface tension and helps keep alveoli open. Reduced surfactant
promotes alveolar collapse.
6. A client with a chest tube reports burning discomfort at the insertion site. Which
intervention is appropriate?
A. Clamp the tube
B. Strip the tubing
C. Increase suction independently
D. Reposition the client and assess the insertion site and drainage system
Answer: D. Reposition the client and assess the insertion site and drainage system
Rationale: Repositioning may improve comfort while the nurse assesses for complications.
,7. A client receiving conscious sedation becomes unresponsive to verbal stimuli. What is the
priority?
A. Document the finding
B. Continue monitoring without intervention
C. Assess airway and breathing immediately
D. Offer oral fluids
Answer: C. Assess airway and breathing immediately
Rationale: Excessive sedation can cause airway obstruction and respiratory depression.
8. A nurse is suctioning a mechanically ventilated client. The client's heart rate becomes
irregular. Which intervention is appropriate?
A. Continue suctioning for 30 seconds
B. Stop suctioning and provide oxygenation as indicated
C. Increase suction pressure
D. Administer an antidysrhythmic immediately
Answer: B. Stop suctioning and provide oxygenation as indicated
Rationale: Suctioning can cause hypoxemia and dysrhythmias. The procedure should be stopped
and oxygenation restored.
9. Before suctioning an endotracheal tube, which intervention is important?
A. Restrict oxygen
B. Preoxygenate the client according to protocol
C. Place the client flat
D. Suction continuously for 30 seconds
Answer: B. Preoxygenate the client according to protocol
Rationale: Preoxygenation helps reduce the risk of hypoxemia during suctioning.
10. A mechanically ventilated client receiving propofol is responsive to verbal commands,
calm, and comfortable. How should the nurse interpret this finding?
, A. Excessive sedation
B. Inadequate sedation
C. Appropriate sedation level
D. Respiratory failure
Answer: C. Appropriate sedation level
Rationale: The desired level of sedation depends on the clinical situation, but excessive
unresponsiveness is generally not the goal when light sedation is prescribed.
11. A client receiving IV vancomycin develops flushing and itching of the face, neck, and
upper torso during the infusion. What should the nurse do first?
A. Increase the infusion rate
B. Continue the infusion unchanged
C. Stop the infusion and notify the provider according to protocol
D. Administer the next dose early
Answer: C. Stop the infusion and notify the provider according to protocol
Rationale: Rapid vancomycin infusion can cause an infusion reaction characterized by flushing
and itching. The infusion should be stopped and managed appropriately.
12. A client receiving IV morphine has a blood pressure of 88/52 mmHg. Why should the
nurse be concerned?
A. Morphine always causes hypertension
B. Morphine can worsen hypotension and cause respiratory/CNS depression
C. The blood pressure is expected in every client
D. Morphine increases circulating volume
Answer: B. Morphine can worsen hypotension and cause respiratory/CNS depression
Rationale: Opioids can cause hypotension, sedation, and respiratory depression, so significant
hypotension warrants assessment before administration.
13. A client receiving a continuous heparin infusion develops abdominal pain and black,
tarry stools. Which medication may be prescribed to reverse heparin's effect?
with correct answers plus rationales 2026/2027 version
1. A client has a chest tube connected to a water-seal drainage system. Which finding
indicates that the client's lung has likely re-expanded?
A. Continuous bubbling in the water-seal chamber
B. Absence of expected tidaling in the water-seal chamber when the lung has re-expanded
C. Increasing subcutaneous emphysema
D. Sudden severe dyspnea
Answer: B. Absence of expected tidaling in the water-seal chamber when the lung has re-
expanded
Rationale: Tidaling can cease when the lung has fully re-expanded, although the nurse should
also assess the entire system and the client's respiratory status.
2. A client with a chest tube has continuous bubbling in the water-seal chamber. What
should the nurse suspect?
A. Normal lung re-expansion
B. An air leak
C. Fluid overload
D. Pulmonary edema
Answer: B. An air leak
Rationale: Continuous bubbling in the water-seal chamber generally indicates an air leak
somewhere in the system.
3. A client has just returned from a bronchoscopy. Which nursing action is appropriate?
A. Offer oral fluids immediately
B. Encourage solid food
C. Withhold oral intake until the gag reflex returns
D. Place the client in Trendelenburg position
Answer: C. Withhold oral intake until the gag reflex returns
Rationale: Local anesthesia used during bronchoscopy can temporarily impair the gag reflex,
increasing aspiration risk.
,4. A client develops a pulmonary embolism. Which medication should the nurse anticipate?
A. Furosemide
B. Atropine
C. Heparin
D. Acetaminophen
Answer: C. Heparin
Rationale: Anticoagulation is commonly initiated to prevent further clot formation and
embolization when clinically appropriate.
5. A client with ARDS has inadequate surfactant production. Which consequence should
the nurse expect?
A. Increased alveolar stability
B. Increased lung compliance
C. Alveolar collapse and decreased lung compliance
D. Increased oxygen diffusion
Answer: C. Alveolar collapse and decreased lung compliance
Rationale: Surfactant reduces surface tension and helps keep alveoli open. Reduced surfactant
promotes alveolar collapse.
6. A client with a chest tube reports burning discomfort at the insertion site. Which
intervention is appropriate?
A. Clamp the tube
B. Strip the tubing
C. Increase suction independently
D. Reposition the client and assess the insertion site and drainage system
Answer: D. Reposition the client and assess the insertion site and drainage system
Rationale: Repositioning may improve comfort while the nurse assesses for complications.
,7. A client receiving conscious sedation becomes unresponsive to verbal stimuli. What is the
priority?
A. Document the finding
B. Continue monitoring without intervention
C. Assess airway and breathing immediately
D. Offer oral fluids
Answer: C. Assess airway and breathing immediately
Rationale: Excessive sedation can cause airway obstruction and respiratory depression.
8. A nurse is suctioning a mechanically ventilated client. The client's heart rate becomes
irregular. Which intervention is appropriate?
A. Continue suctioning for 30 seconds
B. Stop suctioning and provide oxygenation as indicated
C. Increase suction pressure
D. Administer an antidysrhythmic immediately
Answer: B. Stop suctioning and provide oxygenation as indicated
Rationale: Suctioning can cause hypoxemia and dysrhythmias. The procedure should be stopped
and oxygenation restored.
9. Before suctioning an endotracheal tube, which intervention is important?
A. Restrict oxygen
B. Preoxygenate the client according to protocol
C. Place the client flat
D. Suction continuously for 30 seconds
Answer: B. Preoxygenate the client according to protocol
Rationale: Preoxygenation helps reduce the risk of hypoxemia during suctioning.
10. A mechanically ventilated client receiving propofol is responsive to verbal commands,
calm, and comfortable. How should the nurse interpret this finding?
, A. Excessive sedation
B. Inadequate sedation
C. Appropriate sedation level
D. Respiratory failure
Answer: C. Appropriate sedation level
Rationale: The desired level of sedation depends on the clinical situation, but excessive
unresponsiveness is generally not the goal when light sedation is prescribed.
11. A client receiving IV vancomycin develops flushing and itching of the face, neck, and
upper torso during the infusion. What should the nurse do first?
A. Increase the infusion rate
B. Continue the infusion unchanged
C. Stop the infusion and notify the provider according to protocol
D. Administer the next dose early
Answer: C. Stop the infusion and notify the provider according to protocol
Rationale: Rapid vancomycin infusion can cause an infusion reaction characterized by flushing
and itching. The infusion should be stopped and managed appropriately.
12. A client receiving IV morphine has a blood pressure of 88/52 mmHg. Why should the
nurse be concerned?
A. Morphine always causes hypertension
B. Morphine can worsen hypotension and cause respiratory/CNS depression
C. The blood pressure is expected in every client
D. Morphine increases circulating volume
Answer: B. Morphine can worsen hypotension and cause respiratory/CNS depression
Rationale: Opioids can cause hypotension, sedation, and respiratory depression, so significant
hypotension warrants assessment before administration.
13. A client receiving a continuous heparin infusion develops abdominal pain and black,
tarry stools. Which medication may be prescribed to reverse heparin's effect?
