Exam 2 prep NUR 265 LATEST EXAM
Questions with Accurate Answers
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?
Dry mucous membranes
Rhonchi in upper lobes
Blood-tinged sputum
Constant, nonproductive coughing - ANSWERSConstant, nonproductive coughing
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?
Raise the head of bed to high Fowlers
Assess the airway
Suction the client.
Perform chest physiotherapy. - ANSWERSAssess the airway
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should
the nurse take to prepare the patient for the procedure?
Position the patient sitting upright on the edge of the bed and leaning forward.
Start a peripheral IV line to administer the necessary sedative drugs.
Remove the water pitcher and remind the patient not to eat or drink anything for 6
hours.
Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. -
ANSWERSPosition the patient sitting upright on the edge of the bed and leaning
forward.
A client with a blood sugar of 525 g/dl and potassium level of 6.8 mEq/L exhibits
Kussmaul's respiration, confusion, and fruity breath. Which of the following prescriptions
would the nurse anticipate:
3% normal saline IV gtt at 25 mLs/hr
Sodium bicarbonate infusion and Regular Insulin gtt
40 mg Furosemide IVP
6L O2 via nasal cannula - ANSWERSSodium bicarbonate infusion and Regular Insulin
gtt
, The nurse palpates the posterior chest while the client says "99" and notes absent
fremitus. Which action should the nurse take next?
Encourage the client to turn, cough, and deep breathe.
Palpate the anterior chest and observe for barrel chest.
Review the chest x-ray report for evidence of pneumonia.
Auscultate anterior and posterior breath sounds bilaterally. - ANSWERSAuscultate
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?
Urinary output of 25 mL/hr
Respiratory rate of 30 breaths/min
+2 dependent edema to bilateral extremities
Heart rate of 115 beats/min - ANSWERSUrinary output of 25 mL/hr
After receiving change-of-shift report about the following four clients, which client should
the nurse assess first?
A client with metastatic bone cancer has a pleural friction rub and pain upon inspiration.
A client receiving mechanical ventilation via ET tube has the high alarm sounding and
noted with copious secretions.
A client with Diabetes Insipidus whose urine output has been 300mLs/hr, and due for a
scheduled dose of desmopressin po.
A client with a right sided hemothorax and chest tube drainage noted at 50 mL over the
last two hours. - ANSWERSA client receiving mechanical ventilation via ET tube has the
high alarm sounding and noted with copious secretions.
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?
pH 7.31, PaO2 81 mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% - ANSWERSpH 7.31,
PaO2 81 mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
Which is appropriate teaching for the client with newly diagnosed adrenal insufficiency?
Avoidnace of foods high in tyramine
Symptoms that indicate developing adrenal crisis
The need for avoiding high impact activities
The necessity for keeping yearly follow-up appointments - ANSWERSSymptoms that
indicate developing adrenal crisis
Questions with Accurate Answers
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?
Dry mucous membranes
Rhonchi in upper lobes
Blood-tinged sputum
Constant, nonproductive coughing - ANSWERSConstant, nonproductive coughing
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?
Raise the head of bed to high Fowlers
Assess the airway
Suction the client.
Perform chest physiotherapy. - ANSWERSAssess the airway
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should
the nurse take to prepare the patient for the procedure?
Position the patient sitting upright on the edge of the bed and leaning forward.
Start a peripheral IV line to administer the necessary sedative drugs.
Remove the water pitcher and remind the patient not to eat or drink anything for 6
hours.
Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. -
ANSWERSPosition the patient sitting upright on the edge of the bed and leaning
forward.
A client with a blood sugar of 525 g/dl and potassium level of 6.8 mEq/L exhibits
Kussmaul's respiration, confusion, and fruity breath. Which of the following prescriptions
would the nurse anticipate:
3% normal saline IV gtt at 25 mLs/hr
Sodium bicarbonate infusion and Regular Insulin gtt
40 mg Furosemide IVP
6L O2 via nasal cannula - ANSWERSSodium bicarbonate infusion and Regular Insulin
gtt
, The nurse palpates the posterior chest while the client says "99" and notes absent
fremitus. Which action should the nurse take next?
Encourage the client to turn, cough, and deep breathe.
Palpate the anterior chest and observe for barrel chest.
Review the chest x-ray report for evidence of pneumonia.
Auscultate anterior and posterior breath sounds bilaterally. - ANSWERSAuscultate
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?
Urinary output of 25 mL/hr
Respiratory rate of 30 breaths/min
+2 dependent edema to bilateral extremities
Heart rate of 115 beats/min - ANSWERSUrinary output of 25 mL/hr
After receiving change-of-shift report about the following four clients, which client should
the nurse assess first?
A client with metastatic bone cancer has a pleural friction rub and pain upon inspiration.
A client receiving mechanical ventilation via ET tube has the high alarm sounding and
noted with copious secretions.
A client with Diabetes Insipidus whose urine output has been 300mLs/hr, and due for a
scheduled dose of desmopressin po.
A client with a right sided hemothorax and chest tube drainage noted at 50 mL over the
last two hours. - ANSWERSA client receiving mechanical ventilation via ET tube has the
high alarm sounding and noted with copious secretions.
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?
pH 7.31, PaO2 81 mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% - ANSWERSpH 7.31,
PaO2 81 mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
Which is appropriate teaching for the client with newly diagnosed adrenal insufficiency?
Avoidnace of foods high in tyramine
Symptoms that indicate developing adrenal crisis
The need for avoiding high impact activities
The necessity for keeping yearly follow-up appointments - ANSWERSSymptoms that
indicate developing adrenal crisis
