PORTAGE LEARNING NURS 231
PATHOPHYSIOLOGY 2 CONCEPT REVIEW
GUIDE 2026 DISEASE PROGRESSION AND
CLINICAL REASONING
◉ A pt has been admitted with a diagnosis of PE and is receiving
heparin infusion. What safety priority does the nurse include in the
plan of care?
a) Notify radiology of an impending scan.
b) Ensure adequate staffing for the unit.
c) Monitor the platelet count daily.
d) Teach the client to avoid using dental floss.
Answer: c) Monitor the platelet count daily.
*Daily platelet counts are a safety priority in assessing for heparin
induced thrombocytopenia, a potential side effect of heparin.
Avoiding the use of dental floss is important during anticoagulation
therapy, but it is not the priority.
◉ A client in ICU who is receiving mechanical ventilation begins to
pick at the bedcovers. Which action will the nurse take next?
a) Request that the family leave to decrease the client's agitation.
b) Assess for adequate oxygenation.
,c) Explain that the tube in the client's throat helps with breathing.
d) Increase the sedation..
Answer: b) Assess for adequate oxygenation.
*Restlessness, agitation, anxiety, and tachycardia are early
symptoms of hypoxemia. Increasing sedation is not indicated for this
pt and may mask symptoms such as hypoxemia or worsening
respiratory failure.
◉ The nurse is caring for a group of clients with respiratory
disorders. For which of these clients does the nurse plan for
immediate intubation?
a) Client who requires suctioning of oral secretions
b) Client with O2 saturation of 90%
c) Client with hypoventilation and decreased breath sounds
d) Client with thick, purulent secretions and crackles.
Answer: c) Client with hypoventilation and decreased breath sounds
*There is no indication that the client with difficulty handling oral
secretions or who has purulent sputum has hypoxemia or airway
obstruction interfering with swallowing. Suctioning of oral
secretions, rather than intubation, is indicated while continuing to
monitor for hypoxemia, aspiration, and pneumonia. Intubation may
be indicated for the client with an O2 saturation of less than 90%
and other symptoms of hypoxemia or hypercarbia.
,◉ The nurse is assessing a client who is receiving mechanical
ventilation with positive end-expiratory pressure. Which findings
would cause the nurse to suspect a left-sided tension
pneumothorax?
a) Chest asymmetry and jugular vein distention are present.
b) The client has bloody sputum and wheezes.
c) The left lung field is dull to percussion with crackles present on
auscultation.
d) The left chest caves in on inspiration and "puffs out" on
expiration..
Answer: a) Chest asymmetry and jugular vein distention are present.
*Symptoms of tension pneumothorax include chest asymmetry,
tracheal deviation toward the unaffected side, dyspnea, absent
breath sounds, JVD, cyanosis. If not promptly detected and treated,
tension pneumothorax is quickly fatal.
◉ The charge nurse in the intensive care unit is overseeing care for a
group of clients. The nurse is especially vigilant in collaboration with
the primary nurse and interprofessional team in assessing for ARDS
in which of these clients?
a) Client with acute kidney failure
b) Client with aspiration pneumonia
c) Client with atrial fibrillation
, d) Client with DKA.
Answer: b) Client with aspiration pneumonia
*Acute Respiratory Distress Syndrome is characterized by
widespread inflammation in the lungs. Aspiration of acidic gastric
contents promotes inflammation and is a risk for ARDS.
*Clients with DKA may develop metabolic acidosis, but do not
typically ARDS, which develops as a result of lung injury. Atrial
fibrillation does not cause lung injury unless embolization occurs.
Acute kidney failure results in metabolic acidosis, not in acute lung
injury.
◉ The nurse is providing education about the management of
respiratory failure to the family of a client who is receiving
mechanical ventilation. Which statement reflects the MOST
appropriate info that the nurse will communicate?
a) "Paralytics and sedatives help decrease the demand for oxygen."
b) "Sedation is needed so your loved one does not rip the breathing
tube out."
c) "Suctioning is important to remove organisms from the lower
airway."
d) "We are encouraging oral and IV fluids to keep your loved one
hydrated.".
Answer: a) "Paralytics and sedatives help decrease the demand for
oxygen."
PATHOPHYSIOLOGY 2 CONCEPT REVIEW
GUIDE 2026 DISEASE PROGRESSION AND
CLINICAL REASONING
◉ A pt has been admitted with a diagnosis of PE and is receiving
heparin infusion. What safety priority does the nurse include in the
plan of care?
a) Notify radiology of an impending scan.
b) Ensure adequate staffing for the unit.
c) Monitor the platelet count daily.
d) Teach the client to avoid using dental floss.
Answer: c) Monitor the platelet count daily.
*Daily platelet counts are a safety priority in assessing for heparin
induced thrombocytopenia, a potential side effect of heparin.
Avoiding the use of dental floss is important during anticoagulation
therapy, but it is not the priority.
◉ A client in ICU who is receiving mechanical ventilation begins to
pick at the bedcovers. Which action will the nurse take next?
a) Request that the family leave to decrease the client's agitation.
b) Assess for adequate oxygenation.
,c) Explain that the tube in the client's throat helps with breathing.
d) Increase the sedation..
Answer: b) Assess for adequate oxygenation.
*Restlessness, agitation, anxiety, and tachycardia are early
symptoms of hypoxemia. Increasing sedation is not indicated for this
pt and may mask symptoms such as hypoxemia or worsening
respiratory failure.
◉ The nurse is caring for a group of clients with respiratory
disorders. For which of these clients does the nurse plan for
immediate intubation?
a) Client who requires suctioning of oral secretions
b) Client with O2 saturation of 90%
c) Client with hypoventilation and decreased breath sounds
d) Client with thick, purulent secretions and crackles.
Answer: c) Client with hypoventilation and decreased breath sounds
*There is no indication that the client with difficulty handling oral
secretions or who has purulent sputum has hypoxemia or airway
obstruction interfering with swallowing. Suctioning of oral
secretions, rather than intubation, is indicated while continuing to
monitor for hypoxemia, aspiration, and pneumonia. Intubation may
be indicated for the client with an O2 saturation of less than 90%
and other symptoms of hypoxemia or hypercarbia.
,◉ The nurse is assessing a client who is receiving mechanical
ventilation with positive end-expiratory pressure. Which findings
would cause the nurse to suspect a left-sided tension
pneumothorax?
a) Chest asymmetry and jugular vein distention are present.
b) The client has bloody sputum and wheezes.
c) The left lung field is dull to percussion with crackles present on
auscultation.
d) The left chest caves in on inspiration and "puffs out" on
expiration..
Answer: a) Chest asymmetry and jugular vein distention are present.
*Symptoms of tension pneumothorax include chest asymmetry,
tracheal deviation toward the unaffected side, dyspnea, absent
breath sounds, JVD, cyanosis. If not promptly detected and treated,
tension pneumothorax is quickly fatal.
◉ The charge nurse in the intensive care unit is overseeing care for a
group of clients. The nurse is especially vigilant in collaboration with
the primary nurse and interprofessional team in assessing for ARDS
in which of these clients?
a) Client with acute kidney failure
b) Client with aspiration pneumonia
c) Client with atrial fibrillation
, d) Client with DKA.
Answer: b) Client with aspiration pneumonia
*Acute Respiratory Distress Syndrome is characterized by
widespread inflammation in the lungs. Aspiration of acidic gastric
contents promotes inflammation and is a risk for ARDS.
*Clients with DKA may develop metabolic acidosis, but do not
typically ARDS, which develops as a result of lung injury. Atrial
fibrillation does not cause lung injury unless embolization occurs.
Acute kidney failure results in metabolic acidosis, not in acute lung
injury.
◉ The nurse is providing education about the management of
respiratory failure to the family of a client who is receiving
mechanical ventilation. Which statement reflects the MOST
appropriate info that the nurse will communicate?
a) "Paralytics and sedatives help decrease the demand for oxygen."
b) "Sedation is needed so your loved one does not rip the breathing
tube out."
c) "Suctioning is important to remove organisms from the lower
airway."
d) "We are encouraging oral and IV fluids to keep your loved one
hydrated.".
Answer: a) "Paralytics and sedatives help decrease the demand for
oxygen."
