NURS 480 EXAM 1 SPRING II SECTION 1M |ATI NURSING EXAM ACTUAL
2026/2027 TEST BANK PRACTICE QUESTIONS AND STUDY GUIDE
ACCURATE EXAM
1. A nurse is caring for a client who has a newly inserted chest tube connected
to a closed-chest water-seal drainage system. During the assessment, the
nurse notices continuous bubbling in the water-seal chamber while the
client is breathing spontaneously. Which of the following actions should the
nurse take first?
A. Increase the prescribed wall suction
B. Assess the system for an air leak
C. Clamp the chest tube near the insertion site
D. Empty the drainage chamber immediately
Answer: B
2. A client with a tension pneumothorax suddenly develops severe dyspnea,
hypotension, absent breath sounds on the affected side, and tracheal
deviation. The nurse recognizes these findings as a life-threatening
complication. Which intervention should the nurse anticipate?
A. Administration of an oral bronchodilator
B. Placement of the client in a flat supine position
C. Immediate decompression of the affected chest
D. Administration of a loop diuretic
Answer: C
3. A nurse is caring for a client who has acute respiratory distress syndrome
and is receiving mechanical ventilation. Which assessment finding requires
the nurse to recognize that the client's oxygenation problem remains severe
despite supplemental oxygen?
A. Persistent hypoxemia despite high-concentration oxygen therapy
B. Respiratory rate of 18/min with clear bilateral breath sounds
C. Oxygen saturation of 99% while receiving room air
D. Mild anxiety that resolves after reassurance
Answer: A
pg. 1
, 4. A mechanically ventilated client suddenly triggers a high-pressure alarm.
The nurse assesses the client and finds coarse crackles, visible respiratory
secretions, and increased work of breathing. Which action should the nurse
take first?
A. Decrease the prescribed oxygen concentration
B. Disconnect the ventilator permanently
C. Administer a sedative before assessing the airway
D. Assess and suction the airway as indicated
Answer: D
5. A mechanically ventilated client triggers a low-pressure alarm, and the
nurse finds that the ventilator tubing has become disconnected from the
endotracheal tube. Which action is the priority?
A. Reconnect the ventilator tubing and assess the client's respiratory status
B. Increase the ventilator tidal volume
C. Administer an intravenous diuretic
D. Silence the alarm and document the event
Answer: A
6. A client who has a pulmonary embolism suddenly develops dyspnea,
pleuritic chest pain, tachycardia, and anxiety. Which medication should the
nurse anticipate administering to reduce further clot formation?
A. Furosemide
B. Heparin
C. Atropine
D. Dexamethasone
Answer: B
7. A nurse is caring for a client immediately after bronchoscopy. The client asks
for water because of throat dryness. Which action should the nurse take?
A. Provide ice chips immediately
B. Offer clear liquids in small amounts
C. Keep the client NPO until the gag reflex returns
pg. 2
, D. Encourage the client to drink warm fluids
Answer: C
8. A client with severe chronic respiratory disease is receiving oxygen therapy.
The nurse understands that oxygen administration should be carefully
monitored because excessive oxygen can worsen carbon dioxide retention
in susceptible clients. Which assessment is most important?
A. Hair and skin texture
B. Bowel sounds
C. Nail length
D. Respiratory status and level of consciousness
Answer: D
9. A nurse is caring for a client with a tracheostomy who develops noisy
respirations and visible thick secretions around the airway. Which
intervention is most appropriate?
A. Assess the airway and suction the tracheostomy as indicated
B. Remove the tracheostomy tube immediately without assistance
C. Encourage the client to drink carbonated beverages
D. Place the client flat and restrict coughing
Answer: A
10. A client with a chest tube has a sudden increase in dyspnea and the
drainage system becomes disconnected from the tubing. Which action
should the nurse take?
A. Leave the system disconnected while obtaining a replacement
B. Place the end of the chest tube in sterile water
C. Clamp the chest tube for several hours
D. Remove the chest tube and apply a dry dressing
Answer: B
11. A nurse is caring for a client experiencing an acute myocardial infarction.
The client reports severe substernal chest pressure radiating to the left arm
and becomes diaphoretic. Which assessment finding requires immediate
attention?
pg. 3
, A. Heart rate of 88/min
B. Respiratory rate of 18/min
C. New onset ventricular dysrhythmia
D. Mild nausea after receiving medication
Answer: C
12. A client with acute coronary syndrome is prescribed sublingual
nitroglycerin. Which finding should cause the nurse to withhold the
medication and notify the provider?
A. Blood pressure of 88/54 mm Hg
B. Heart rate of 92/min
C. Respiratory rate of 20/min
D. Oxygen saturation of 96%
Answer: A
13. A client receiving digoxin for heart failure reports nausea and visual
disturbances and has an apical heart rate of 48/min. Which action should
the nurse take?
A. Administer the medication with food
B. Encourage additional potassium intake
C. Hold the digoxin and notify the provider
D. Administer the next dose early
Answer: C
14. A client receiving spironolactone for heart failure has a serum potassium
level of 5.9 mEq/L. Which action should the nurse take?
A. Encourage bananas and orange juice
B. Hold the medication and notify the provider
C. Administer potassium supplementation
D. Increase the prescribed spironolactone dose
Answer: B
15. A client with acute decompensated heart failure has severe dyspnea,
crackles throughout both lung fields, and frothy sputum. Which
intervention should the nurse implement first?
pg. 4
2026/2027 TEST BANK PRACTICE QUESTIONS AND STUDY GUIDE
ACCURATE EXAM
1. A nurse is caring for a client who has a newly inserted chest tube connected
to a closed-chest water-seal drainage system. During the assessment, the
nurse notices continuous bubbling in the water-seal chamber while the
client is breathing spontaneously. Which of the following actions should the
nurse take first?
A. Increase the prescribed wall suction
B. Assess the system for an air leak
C. Clamp the chest tube near the insertion site
D. Empty the drainage chamber immediately
Answer: B
2. A client with a tension pneumothorax suddenly develops severe dyspnea,
hypotension, absent breath sounds on the affected side, and tracheal
deviation. The nurse recognizes these findings as a life-threatening
complication. Which intervention should the nurse anticipate?
A. Administration of an oral bronchodilator
B. Placement of the client in a flat supine position
C. Immediate decompression of the affected chest
D. Administration of a loop diuretic
Answer: C
3. A nurse is caring for a client who has acute respiratory distress syndrome
and is receiving mechanical ventilation. Which assessment finding requires
the nurse to recognize that the client's oxygenation problem remains severe
despite supplemental oxygen?
A. Persistent hypoxemia despite high-concentration oxygen therapy
B. Respiratory rate of 18/min with clear bilateral breath sounds
C. Oxygen saturation of 99% while receiving room air
D. Mild anxiety that resolves after reassurance
Answer: A
pg. 1
, 4. A mechanically ventilated client suddenly triggers a high-pressure alarm.
The nurse assesses the client and finds coarse crackles, visible respiratory
secretions, and increased work of breathing. Which action should the nurse
take first?
A. Decrease the prescribed oxygen concentration
B. Disconnect the ventilator permanently
C. Administer a sedative before assessing the airway
D. Assess and suction the airway as indicated
Answer: D
5. A mechanically ventilated client triggers a low-pressure alarm, and the
nurse finds that the ventilator tubing has become disconnected from the
endotracheal tube. Which action is the priority?
A. Reconnect the ventilator tubing and assess the client's respiratory status
B. Increase the ventilator tidal volume
C. Administer an intravenous diuretic
D. Silence the alarm and document the event
Answer: A
6. A client who has a pulmonary embolism suddenly develops dyspnea,
pleuritic chest pain, tachycardia, and anxiety. Which medication should the
nurse anticipate administering to reduce further clot formation?
A. Furosemide
B. Heparin
C. Atropine
D. Dexamethasone
Answer: B
7. A nurse is caring for a client immediately after bronchoscopy. The client asks
for water because of throat dryness. Which action should the nurse take?
A. Provide ice chips immediately
B. Offer clear liquids in small amounts
C. Keep the client NPO until the gag reflex returns
pg. 2
, D. Encourage the client to drink warm fluids
Answer: C
8. A client with severe chronic respiratory disease is receiving oxygen therapy.
The nurse understands that oxygen administration should be carefully
monitored because excessive oxygen can worsen carbon dioxide retention
in susceptible clients. Which assessment is most important?
A. Hair and skin texture
B. Bowel sounds
C. Nail length
D. Respiratory status and level of consciousness
Answer: D
9. A nurse is caring for a client with a tracheostomy who develops noisy
respirations and visible thick secretions around the airway. Which
intervention is most appropriate?
A. Assess the airway and suction the tracheostomy as indicated
B. Remove the tracheostomy tube immediately without assistance
C. Encourage the client to drink carbonated beverages
D. Place the client flat and restrict coughing
Answer: A
10. A client with a chest tube has a sudden increase in dyspnea and the
drainage system becomes disconnected from the tubing. Which action
should the nurse take?
A. Leave the system disconnected while obtaining a replacement
B. Place the end of the chest tube in sterile water
C. Clamp the chest tube for several hours
D. Remove the chest tube and apply a dry dressing
Answer: B
11. A nurse is caring for a client experiencing an acute myocardial infarction.
The client reports severe substernal chest pressure radiating to the left arm
and becomes diaphoretic. Which assessment finding requires immediate
attention?
pg. 3
, A. Heart rate of 88/min
B. Respiratory rate of 18/min
C. New onset ventricular dysrhythmia
D. Mild nausea after receiving medication
Answer: C
12. A client with acute coronary syndrome is prescribed sublingual
nitroglycerin. Which finding should cause the nurse to withhold the
medication and notify the provider?
A. Blood pressure of 88/54 mm Hg
B. Heart rate of 92/min
C. Respiratory rate of 20/min
D. Oxygen saturation of 96%
Answer: A
13. A client receiving digoxin for heart failure reports nausea and visual
disturbances and has an apical heart rate of 48/min. Which action should
the nurse take?
A. Administer the medication with food
B. Encourage additional potassium intake
C. Hold the digoxin and notify the provider
D. Administer the next dose early
Answer: C
14. A client receiving spironolactone for heart failure has a serum potassium
level of 5.9 mEq/L. Which action should the nurse take?
A. Encourage bananas and orange juice
B. Hold the medication and notify the provider
C. Administer potassium supplementation
D. Increase the prescribed spironolactone dose
Answer: B
15. A client with acute decompensated heart failure has severe dyspnea,
crackles throughout both lung fields, and frothy sputum. Which
intervention should the nurse implement first?
pg. 4
