NUR 265 UPDATED Questions and
CORRECT Answers
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 . - CORRECT ANSWER c ) Assess the airway .
A client has a new tracheostomy , on a mechanical ventilator with the following settings : SIMV
, rate of 12 TV 800 , Flo2 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 - CORRECT ANSWER d ) Constant ,
nonproductive coughing
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 . - CORRECT ANSWER c)
Auscultate anterior and posterior breath sounds bilaterally .
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 - CORRECT ANSWER d ) Urinary output of 25 mL / hr
The nurse has been made aware of the arterial blood gas ( ABG ) results on four clients . Which
result is most important for the nurse to report immediately to the health care provider ?
a ) pH 7.46 , PaO2 90 mm Hg , PaCO2 32 mm Hg , and O2 sat 98 %
b ) pH 7.35 , PaO2 85 mm Hg , PaCO2 45 mm Hg , and O2 sat 95 %
c ) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
d ) pH 7.34 , PaO2 82 mm Hg , PaCO2 40 mm Hg , and O2 sat 97 % - CORRECT
ANSWER c ) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
The nurse monitors a client immediately following a chest tube insertion for a
hemopneumothorax . Which of the following assessment findings requires immediate follow up
?
a ) 400 ml of blood in the collection chamber
b ) Tidaling in the water - seal chamber
c ) Platelet count 151,000 / micro / L
d ) Subcutaneous emphysema at the insertion site - CORRECT ANSWER a ) 400 ml of
blood in the collection chamber
When assessing a client who has just arrived after an automobile accident , the emergency
department nurse notes heart rate of 125 bpm and absent breath sounds over the right lung .
Which of the following actions is priority ?
a ) Administration of an inhaled bronchodilator
b ) Insertion of a chest tube with a chest drainage system
c ) Prepare for oral intubation with mechanical ventilation
d ) Send client for a stat CT scan of the thorax - CORRECT ANSWER b ) Insertion of a
chest tube with a chest drainage system
CORRECT Answers
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 . - CORRECT ANSWER c ) Assess the airway .
A client has a new tracheostomy , on a mechanical ventilator with the following settings : SIMV
, rate of 12 TV 800 , Flo2 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 - CORRECT ANSWER d ) Constant ,
nonproductive coughing
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 . - CORRECT ANSWER c)
Auscultate anterior and posterior breath sounds bilaterally .
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 - CORRECT ANSWER d ) Urinary output of 25 mL / hr
The nurse has been made aware of the arterial blood gas ( ABG ) results on four clients . Which
result is most important for the nurse to report immediately to the health care provider ?
a ) pH 7.46 , PaO2 90 mm Hg , PaCO2 32 mm Hg , and O2 sat 98 %
b ) pH 7.35 , PaO2 85 mm Hg , PaCO2 45 mm Hg , and O2 sat 95 %
c ) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
d ) pH 7.34 , PaO2 82 mm Hg , PaCO2 40 mm Hg , and O2 sat 97 % - CORRECT
ANSWER c ) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
The nurse monitors a client immediately following a chest tube insertion for a
hemopneumothorax . Which of the following assessment findings requires immediate follow up
?
a ) 400 ml of blood in the collection chamber
b ) Tidaling in the water - seal chamber
c ) Platelet count 151,000 / micro / L
d ) Subcutaneous emphysema at the insertion site - CORRECT ANSWER a ) 400 ml of
blood in the collection chamber
When assessing a client who has just arrived after an automobile accident , the emergency
department nurse notes heart rate of 125 bpm and absent breath sounds over the right lung .
Which of the following actions is priority ?
a ) Administration of an inhaled bronchodilator
b ) Insertion of a chest tube with a chest drainage system
c ) Prepare for oral intubation with mechanical ventilation
d ) Send client for a stat CT scan of the thorax - CORRECT ANSWER b ) Insertion of a
chest tube with a chest drainage system
