NUR265 Exam 2 Holmes mock ANSWERED 100% CORRECT

Question 1 2 / 2 pts The nurse notes each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse’s best intervention? a) Suction the client. b) Perform chest physiotherapy. c) Assess the airway. d) Raise the head of bed to high Fowlers. Question 2 2 / 2 pts A client has a new tracheostomy, on a mechanical ventilator with the following settings: SIMV, rate of 12, TV 800, FIo2 80% and PEEP of 5 cmH20. Which assessment finding requires immediate action by the nurse? a) Blood-tinged sputum b) Rhonchi in upper lobes c) Dry mucous membranes d) Constant, nonproductive coughing Question 3 2 / 2 pts The nurse palpates the posterior chest while the client says “99” and notes absent fremitus. Which action should the nurse take next? a) Encourage the client to turn, cough, and deep breathe. b) Review the chest x-ray report for evidence of pneumonia. c) Auscultate anterior and posterior breath sounds bilaterally. d) Palpate the anterior chest and observe for barrel chest. Question 4 2 / 2 pts The nurse is caring for a client with a pulmonary embolus, also has right-sided heart failure. Which clinical findings requires immediate follow up? a) Heart rate of 115 beats/min b) Respiratory rate of 28 breaths/min c) +2 dependent edema to bilateral extremities d) Urinary output of 25 mL/hr