,West Coast NURS 480 Exam 1 | Advanced Medical-
Surgical Nursing (2026) Q&A
1. A client with acute respiratory distress syndrome (ARDS) is receiving mechanical
ventilation with a PEEP of 15 cm H₂O. The nurse notes a sudden drop in blood pressure
and absent breath sounds on the right side. Which complication should the nurse
suspect?
A) Pulmonary embolism
B) Tension pneumothorax
C) Atelectasis
D) Pulmonary edema
Correct Answer: B) Tension pneumothorax
Rationale: High PEEP levels increase the risk of barotrauma, which can lead to a tension
pneumothorax. Sudden hypotension and unilateral absent breath sounds are classic signs.
Immediate intervention is required.
2. A client is admitted with septic shock. Which assessment finding requires the most
immediate intervention?
A) Heart rate of 118 beats/min
B) Mean arterial pressure (MAP) of 58 mm Hg
C) Temperature of 101.2°F
D) Respiratory rate of 24 breaths/min
Correct Answer: B) Mean arterial pressure (MAP) of 58 mm Hg
,Rationale: A MAP below 65 mm Hg in septic shock indicates inadequate organ perfusion
and requires immediate intervention, often with vasopressors. Tachycardia and fever are
expected.
3. A client with a chest tube to a closed drainage system has continuous bubbling in the
water-seal chamber. What is the nurse's priority action?
A) Clamp the chest tube immediately
B) Assess the tubing and insertion site for an air leak
C) Increase the suction level
D) Document the finding as normal
Correct Answer: B) Assess the tubing and insertion site for an air leak
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak. The nurse
should systematically assess connections, tubing, and the insertion site before
interventions.
4. A client is receiving mechanical ventilation. The low-pressure alarm sounds. Which
action should the nurse take first?
A) Manually ventilate the client with a bag-valve-mask
B) Check for disconnection or leak in the ventilator circuit
C) Increase the tidal volume setting
D) Administer a sedative
Correct Answer: B) Check for disconnection or leak in the ventilator circuit
Rationale: A low-pressure alarm indicates a leak or disconnection. The nurse should first
check the circuit for disconnection or leaks before other interventions.
, 5. A client with a pulmonary embolism is started on a heparin infusion. Which laboratory
value should the nurse monitor to evaluate therapeutic effectiveness?
A) Prothrombin time (PT)
B) International Normalized Ratio (INR)
C) Activated partial thromboplastin time (aPTT)
D) Platelet count
Correct Answer: C) Activated partial thromboplastin time (aPTT)
Rationale: Heparin therapy is monitored using aPTT, with a therapeutic goal of 1.5 to 2.5
times the control value. PT/INR monitors warfarin.
6. A client with severe sepsis has a lactate level of 4.2 mmol/L. What does this finding
indicate?
A) Adequate tissue perfusion
B) Anaerobic metabolism and tissue hypoperfusion
C) Normal metabolic function
D) Improved response to fluids
Correct Answer: B) Anaerobic metabolism and tissue hypoperfusion
Rationale: Elevated lactate in sepsis indicates anaerobic metabolism from tissue
hypoperfusion. A level above 2 mmol/L requires immediate intervention.
7. A client in the emergency department has a gunshot wound to the chest and distended
neck veins. Breath sounds are absent on the right. Which action should the nurse take
first?
Surgical Nursing (2026) Q&A
1. A client with acute respiratory distress syndrome (ARDS) is receiving mechanical
ventilation with a PEEP of 15 cm H₂O. The nurse notes a sudden drop in blood pressure
and absent breath sounds on the right side. Which complication should the nurse
suspect?
A) Pulmonary embolism
B) Tension pneumothorax
C) Atelectasis
D) Pulmonary edema
Correct Answer: B) Tension pneumothorax
Rationale: High PEEP levels increase the risk of barotrauma, which can lead to a tension
pneumothorax. Sudden hypotension and unilateral absent breath sounds are classic signs.
Immediate intervention is required.
2. A client is admitted with septic shock. Which assessment finding requires the most
immediate intervention?
A) Heart rate of 118 beats/min
B) Mean arterial pressure (MAP) of 58 mm Hg
C) Temperature of 101.2°F
D) Respiratory rate of 24 breaths/min
Correct Answer: B) Mean arterial pressure (MAP) of 58 mm Hg
,Rationale: A MAP below 65 mm Hg in septic shock indicates inadequate organ perfusion
and requires immediate intervention, often with vasopressors. Tachycardia and fever are
expected.
3. A client with a chest tube to a closed drainage system has continuous bubbling in the
water-seal chamber. What is the nurse's priority action?
A) Clamp the chest tube immediately
B) Assess the tubing and insertion site for an air leak
C) Increase the suction level
D) Document the finding as normal
Correct Answer: B) Assess the tubing and insertion site for an air leak
Rationale: Continuous bubbling in the water-seal chamber indicates an air leak. The nurse
should systematically assess connections, tubing, and the insertion site before
interventions.
4. A client is receiving mechanical ventilation. The low-pressure alarm sounds. Which
action should the nurse take first?
A) Manually ventilate the client with a bag-valve-mask
B) Check for disconnection or leak in the ventilator circuit
C) Increase the tidal volume setting
D) Administer a sedative
Correct Answer: B) Check for disconnection or leak in the ventilator circuit
Rationale: A low-pressure alarm indicates a leak or disconnection. The nurse should first
check the circuit for disconnection or leaks before other interventions.
, 5. A client with a pulmonary embolism is started on a heparin infusion. Which laboratory
value should the nurse monitor to evaluate therapeutic effectiveness?
A) Prothrombin time (PT)
B) International Normalized Ratio (INR)
C) Activated partial thromboplastin time (aPTT)
D) Platelet count
Correct Answer: C) Activated partial thromboplastin time (aPTT)
Rationale: Heparin therapy is monitored using aPTT, with a therapeutic goal of 1.5 to 2.5
times the control value. PT/INR monitors warfarin.
6. A client with severe sepsis has a lactate level of 4.2 mmol/L. What does this finding
indicate?
A) Adequate tissue perfusion
B) Anaerobic metabolism and tissue hypoperfusion
C) Normal metabolic function
D) Improved response to fluids
Correct Answer: B) Anaerobic metabolism and tissue hypoperfusion
Rationale: Elevated lactate in sepsis indicates anaerobic metabolism from tissue
hypoperfusion. A level above 2 mmol/L requires immediate intervention.
7. A client in the emergency department has a gunshot wound to the chest and distended
neck veins. Breath sounds are absent on the right. Which action should the nurse take
first?
