Rasmussen University NUR 2755 Module 5 (pdf) | 2026/2027 | MDC 4
Q&A | Nursing
1. Which of the following arterial blood gas (ABG) findings is most consistent
with a diagnosis of acute respiratory failure?
A) PaO2 55 mm Hg, PaCO2 38 mm Hg, pH 7.36
B) PaO2 65 mm Hg, PaCO2 42 mm Hg, pH 7.40
C) PaO2 58 mm Hg, PaCO2 52 mm Hg, pH 7.30
D) PaO2 88 mm Hg, PaCO2 35 mm Hg, pH 7.45
Correct Answer: PaO2 58 mm Hg, PaCO2 52 mm Hg, pH 7.30
Rationale: Acute respiratory failure is defined as a PaO2 less than 60 mm Hg
and/or a PaCO2 greater than 45 mm Hg with a pH less than 7.35. Option C
shows hypoxemia (PaO2 58), hypercapnia (PaCO2 52), and acidemia (pH
7.30), which meets the criteria for respiratory failure.
2. A client with acute respiratory failure is exhibiting restlessness, irritability,
and tachycardia. The nurse should recognize these as signs of:
A) Hypercapnic respiratory failure
B) Hypoxemic respiratory failure
C) Compensated respiratory acidosis
D) Metabolic alkalosis
Correct Answer: Hypoxemic respiratory failure
Rationale: Hypoxemic respiratory failure is characterized by low oxygen
levels and often presents with restlessness, irritability, agitation, confusion,
and tachycardia. Hypercapnic failure (high CO2) presents with drowsiness,
confusion, headache, and lethargy.
,3. A client with acute respiratory failure is demonstrating drowsiness,
confusion, and lethargy. The nurse should suspect which type of respiratory
failure?
A) Hypoxemic respiratory failure
B) Hypercapnic respiratory failure
C) Ventilation-perfusion mismatch
D) Refractory hypoxemia
Correct Answer: Hypercapnic respiratory failure
Rationale: Hypercapnic respiratory failure is characterized by elevated CO2
levels and presents with decreased level of consciousness, drowsiness,
confusion, headache, lethargy, and seizures. Hypoxemic failure presents with
restlessness and tachycardia.
4. The nurse is caring for a client with acute respiratory distress syndrome
(ARDS). Which finding is most characteristic of this condition?
A) Hypoxemia that improves with supplemental oxygen
B) Refractory hypoxemia that does not improve with 100% oxygen
C) Hypercapnia with normal oxygenation
D) Sudden onset of wheezing
Correct Answer: Refractory hypoxemia that does not improve with 100%
oxygen
Rationale: ARDS is characterized by refractory hypoxemia, where the client
remains hypoxemic even with 100% oxygen due to intrapulmonary shunting
and ventilation-perfusion mismatch. This is a hallmark feature of ARDS.
,5. A client with ARDS is receiving mechanical ventilation. Which nursing
intervention is most important to prevent ventilator-associated pneumonia
(VAP)?
A) Suctioning the client every 2 hours
B) Maintaining the head of the bed elevated at 30-45 degrees
C) Restricting fluid intake
D) Administering bronchodilators
Correct Answer: Maintaining the head of the bed elevated at 30-45 degrees
Rationale: Elevating the head of the bed to 30-45 degrees helps prevent
ventilator-associated pneumonia (VAP) by reducing the risk of aspiration.
Suctioning should be done as needed, not on a fixed schedule.
6. A client with a chest injury has a flail chest. Which assessment finding is
most characteristic of this condition?
A) Diminished breath sounds on the affected side
B) Paradoxical chest movement
C) Absent breath sounds
D) Subcutaneous emphysema
Correct Answer: Paradoxical chest movement
Rationale: Flail chest is characterized by paradoxical chest movement, where
the affected segment moves inward during inspiration and outward during
expiration. This is the most distinctive sign of flail chest.
7. A client with a tension pneumothorax is in severe respiratory distress.
Which intervention should the nurse anticipate?
, A) Chest tube insertion at the 2nd intercostal space
B) Needle decompression at the 2nd intercostal space midclavicular line
C) Chest tube insertion at the 4th intercostal space
D) Oxygen therapy via non-rebreather mask
Correct Answer: Needle decompression at the 2nd intercostal space
midclavicular line
Rationale: Tension pneumothorax is a life-threatening emergency requiring
immediate needle decompression at the 2nd intercostal space, midclavicular
line, followed by chest tube insertion at the 4th intercostal space.
8. A client with a hemothorax is at risk for which complication?
A) Hypertension
B) Bradycardia
C) Hypotension and tachycardia
D) Hyperthermia
Correct Answer: Hypotension and tachycardia
Rationale: Hemothorax involves bleeding into the chest cavity, which can
lead to hypovolemia. Signs include hypotension and tachycardia.
Hypertension and bradycardia are not typical findings.
9. A nurse is caring for a client with a pneumothorax. Which assessment
finding is most consistent with this condition?
A) Tracheal deviation toward the affected side
B) Tracheal deviation away from the midline
C) Bilateral crackles
Q&A | Nursing
1. Which of the following arterial blood gas (ABG) findings is most consistent
with a diagnosis of acute respiratory failure?
A) PaO2 55 mm Hg, PaCO2 38 mm Hg, pH 7.36
B) PaO2 65 mm Hg, PaCO2 42 mm Hg, pH 7.40
C) PaO2 58 mm Hg, PaCO2 52 mm Hg, pH 7.30
D) PaO2 88 mm Hg, PaCO2 35 mm Hg, pH 7.45
Correct Answer: PaO2 58 mm Hg, PaCO2 52 mm Hg, pH 7.30
Rationale: Acute respiratory failure is defined as a PaO2 less than 60 mm Hg
and/or a PaCO2 greater than 45 mm Hg with a pH less than 7.35. Option C
shows hypoxemia (PaO2 58), hypercapnia (PaCO2 52), and acidemia (pH
7.30), which meets the criteria for respiratory failure.
2. A client with acute respiratory failure is exhibiting restlessness, irritability,
and tachycardia. The nurse should recognize these as signs of:
A) Hypercapnic respiratory failure
B) Hypoxemic respiratory failure
C) Compensated respiratory acidosis
D) Metabolic alkalosis
Correct Answer: Hypoxemic respiratory failure
Rationale: Hypoxemic respiratory failure is characterized by low oxygen
levels and often presents with restlessness, irritability, agitation, confusion,
and tachycardia. Hypercapnic failure (high CO2) presents with drowsiness,
confusion, headache, and lethargy.
,3. A client with acute respiratory failure is demonstrating drowsiness,
confusion, and lethargy. The nurse should suspect which type of respiratory
failure?
A) Hypoxemic respiratory failure
B) Hypercapnic respiratory failure
C) Ventilation-perfusion mismatch
D) Refractory hypoxemia
Correct Answer: Hypercapnic respiratory failure
Rationale: Hypercapnic respiratory failure is characterized by elevated CO2
levels and presents with decreased level of consciousness, drowsiness,
confusion, headache, lethargy, and seizures. Hypoxemic failure presents with
restlessness and tachycardia.
4. The nurse is caring for a client with acute respiratory distress syndrome
(ARDS). Which finding is most characteristic of this condition?
A) Hypoxemia that improves with supplemental oxygen
B) Refractory hypoxemia that does not improve with 100% oxygen
C) Hypercapnia with normal oxygenation
D) Sudden onset of wheezing
Correct Answer: Refractory hypoxemia that does not improve with 100%
oxygen
Rationale: ARDS is characterized by refractory hypoxemia, where the client
remains hypoxemic even with 100% oxygen due to intrapulmonary shunting
and ventilation-perfusion mismatch. This is a hallmark feature of ARDS.
,5. A client with ARDS is receiving mechanical ventilation. Which nursing
intervention is most important to prevent ventilator-associated pneumonia
(VAP)?
A) Suctioning the client every 2 hours
B) Maintaining the head of the bed elevated at 30-45 degrees
C) Restricting fluid intake
D) Administering bronchodilators
Correct Answer: Maintaining the head of the bed elevated at 30-45 degrees
Rationale: Elevating the head of the bed to 30-45 degrees helps prevent
ventilator-associated pneumonia (VAP) by reducing the risk of aspiration.
Suctioning should be done as needed, not on a fixed schedule.
6. A client with a chest injury has a flail chest. Which assessment finding is
most characteristic of this condition?
A) Diminished breath sounds on the affected side
B) Paradoxical chest movement
C) Absent breath sounds
D) Subcutaneous emphysema
Correct Answer: Paradoxical chest movement
Rationale: Flail chest is characterized by paradoxical chest movement, where
the affected segment moves inward during inspiration and outward during
expiration. This is the most distinctive sign of flail chest.
7. A client with a tension pneumothorax is in severe respiratory distress.
Which intervention should the nurse anticipate?
, A) Chest tube insertion at the 2nd intercostal space
B) Needle decompression at the 2nd intercostal space midclavicular line
C) Chest tube insertion at the 4th intercostal space
D) Oxygen therapy via non-rebreather mask
Correct Answer: Needle decompression at the 2nd intercostal space
midclavicular line
Rationale: Tension pneumothorax is a life-threatening emergency requiring
immediate needle decompression at the 2nd intercostal space, midclavicular
line, followed by chest tube insertion at the 4th intercostal space.
8. A client with a hemothorax is at risk for which complication?
A) Hypertension
B) Bradycardia
C) Hypotension and tachycardia
D) Hyperthermia
Correct Answer: Hypotension and tachycardia
Rationale: Hemothorax involves bleeding into the chest cavity, which can
lead to hypovolemia. Signs include hypotension and tachycardia.
Hypertension and bradycardia are not typical findings.
9. A nurse is caring for a client with a pneumothorax. Which assessment
finding is most consistent with this condition?
A) Tracheal deviation toward the affected side
B) Tracheal deviation away from the midline
C) Bilateral crackles
