NUR 265 / NUR265 EXAM 2
Advanced Concepts in Medical-
Surgical Nursing EXAM 2 |
Questions and Answers Rated
A+ | 2026/2027
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?
Suction the client.
Correct! Perform chest physiotherapy.
Assess the airway
Raise the head of bed to high Fowlers
-Page 1 of 44
, 2/16/21, 9:46 PM
Question 2
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?
Blood-tinged sputum
Rhonchi in upper lobes
Dry mucous membranes
Correct! Constant, nonproductive coughing
Question 3 pts
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.
Review the chest x-ray report for evidence of pneumonia.
Correct! Auscultate anterior and posterior breath sounds bilaterally.
Palpate the anterior chest and observe for barrel chest.
-Page 2 of 44
, pts
Question 4
The nurse is caring for a client with a pulmonary embolus, also has
right-sided heart failure. Which clinical findings requires immediate
follow up?
Heart rate of 115 beats/min
Respiratory rate of 28 breaths/min
+2 dependent edema to bilateral extremities
Correct! Urinary output of 25 mL/hr
-Page 3 of 44
, 2/16/21, 9:46 PM
pts
Question 5
The nurse has been made aware of the arterial blood gas (ABG) results
on four clients. Which result
mostisimportant for the nurse to report
immediately to the health care provider?
pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
Correct! pH 7.31, PaO2 81mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
-Page 4 of 44
Advanced Concepts in Medical-
Surgical Nursing EXAM 2 |
Questions and Answers Rated
A+ | 2026/2027
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?
Suction the client.
Correct! Perform chest physiotherapy.
Assess the airway
Raise the head of bed to high Fowlers
-Page 1 of 44
, 2/16/21, 9:46 PM
Question 2
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?
Blood-tinged sputum
Rhonchi in upper lobes
Dry mucous membranes
Correct! Constant, nonproductive coughing
Question 3 pts
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.
Review the chest x-ray report for evidence of pneumonia.
Correct! Auscultate anterior and posterior breath sounds bilaterally.
Palpate the anterior chest and observe for barrel chest.
-Page 2 of 44
, pts
Question 4
The nurse is caring for a client with a pulmonary embolus, also has
right-sided heart failure. Which clinical findings requires immediate
follow up?
Heart rate of 115 beats/min
Respiratory rate of 28 breaths/min
+2 dependent edema to bilateral extremities
Correct! Urinary output of 25 mL/hr
-Page 3 of 44
, 2/16/21, 9:46 PM
pts
Question 5
The nurse has been made aware of the arterial blood gas (ABG) results
on four clients. Which result
mostisimportant for the nurse to report
immediately to the health care provider?
pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98%
pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
Correct! pH 7.31, PaO2 81mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
-Page 4 of 44
