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NURS 480 EXAM 1 — ADVANCED MEDICAL-
SURGICAL NURSING QUESTIONS WITH VERIFIED
SOLUTIONS AND RATIONALES
1. The nurse assesses a client with dyspnea, decreased breath sounds, tracheal
deviation, and pulse oximetry reading of 86%. What is the nurse's interpretation
of these findings?
A. Flail chest
B. Tension pneumothorax
C. Pulmonary contusion
D. Acute respiratory distress syndrome
Correct Answer: B
Rationale: Tracheal deviation away from the affected side, decreased breath
sounds, and severe hypoxemia are classic signs of tension pneumothorax, a life-
threatening emergency requiring immediate needle decompression .
2. The nurse observes the nursing student suctioning the client. Which
intervention on the student nurse's part has the greatest potential to cause tissue
damage?
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A. Applying suction when the catheter is inserted
B. Oxygen saturation post-suctioning of 93%
C. Hyperoxygenating the client after removing the suction catheter
D. Applying intermittent suction
Correct Answer: A
Rationale: Suction should only be applied while withdrawing the catheter.
Applying suction during insertion causes mucosal trauma and hypoxia .
3. A client has the following arterial blood gas values: pH 7.52, PaO₂ 50 mm Hg,
PaCO₂ 28 mm Hg, HCO₃ 24 mEq/L. Based upon the client's PaO₂, which of the
following conclusions would be accurate?
A. The client is severely hypoxic
B. The oxygen level is low but poses no risk for the client
C. The client's PaO₂ level is within normal range
D. The client requires oxygen therapy with very low oxygen concentrations
Correct Answer: A
Rationale: A PaO₂ of 50 mm Hg is severely low (normal 80-100 mm Hg), indicating
severe hypoxemia requiring immediate oxygen therapy .
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4. A client who is intubated and receiving mechanical ventilation (PEEP) has a
nursing diagnosis for Risk for Infection. The nurse should include which of the
following in the care of this client? (Select all that apply)
A. Monitor the client's temperature
B. Monitor sputum characteristics and amounts
C. Use the closed-system method of suctioning
D. Use clean technique if suctioning via ETT
Correct Answer: A, B, C
Rationale: Monitoring temperature and sputum, and using closed-system
suctioning reduce infection risk. Sterile technique, not clean technique, is
required for ETT suctioning .
5. A nurse is caring for a client experiencing moderate to severe pain. The client is
scheduled to receive IV morphine as ordered. Which of the following assessment
findings should be a concern for the nurse?
A. Blood pressure: 88/52 mm Hg
B. Client reports of passing stool once in 7 days
C. Respiratory rate: 14 breaths per minute
D. SpO₂: 98% on room air
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Correct Answer: A
Rationale: Morphine causes vasodilation and can cause hypotension. A BP of
88/52 mm Hg is concerning and should be addressed before administering
morphine .
6. A client receiving a continuous IV heparin infusion for a pulmonary embolism
complains of abdominal pain and black tarry stool. Which of the following should
the nurse anticipate as the next intervention?
A. Administer protamine sulfate as ordered
B. Monitor aPTT
C. Monitor PTT
D. Administer Vitamin K as ordered
Correct Answer: A
Rationale: Black tarry stool indicates gastrointestinal bleeding from heparin.
Protamine sulfate is the antidote for heparin and should be administered as
ordered .
7. The nurse is assigned to four clients. Which of the following clients should the
nurse assess first?
NURS 480 EXAM 1 — ADVANCED MEDICAL-
SURGICAL NURSING QUESTIONS WITH VERIFIED
SOLUTIONS AND RATIONALES
1. The nurse assesses a client with dyspnea, decreased breath sounds, tracheal
deviation, and pulse oximetry reading of 86%. What is the nurse's interpretation
of these findings?
A. Flail chest
B. Tension pneumothorax
C. Pulmonary contusion
D. Acute respiratory distress syndrome
Correct Answer: B
Rationale: Tracheal deviation away from the affected side, decreased breath
sounds, and severe hypoxemia are classic signs of tension pneumothorax, a life-
threatening emergency requiring immediate needle decompression .
2. The nurse observes the nursing student suctioning the client. Which
intervention on the student nurse's part has the greatest potential to cause tissue
damage?
,2|Page
A. Applying suction when the catheter is inserted
B. Oxygen saturation post-suctioning of 93%
C. Hyperoxygenating the client after removing the suction catheter
D. Applying intermittent suction
Correct Answer: A
Rationale: Suction should only be applied while withdrawing the catheter.
Applying suction during insertion causes mucosal trauma and hypoxia .
3. A client has the following arterial blood gas values: pH 7.52, PaO₂ 50 mm Hg,
PaCO₂ 28 mm Hg, HCO₃ 24 mEq/L. Based upon the client's PaO₂, which of the
following conclusions would be accurate?
A. The client is severely hypoxic
B. The oxygen level is low but poses no risk for the client
C. The client's PaO₂ level is within normal range
D. The client requires oxygen therapy with very low oxygen concentrations
Correct Answer: A
Rationale: A PaO₂ of 50 mm Hg is severely low (normal 80-100 mm Hg), indicating
severe hypoxemia requiring immediate oxygen therapy .
,3|Page
4. A client who is intubated and receiving mechanical ventilation (PEEP) has a
nursing diagnosis for Risk for Infection. The nurse should include which of the
following in the care of this client? (Select all that apply)
A. Monitor the client's temperature
B. Monitor sputum characteristics and amounts
C. Use the closed-system method of suctioning
D. Use clean technique if suctioning via ETT
Correct Answer: A, B, C
Rationale: Monitoring temperature and sputum, and using closed-system
suctioning reduce infection risk. Sterile technique, not clean technique, is
required for ETT suctioning .
5. A nurse is caring for a client experiencing moderate to severe pain. The client is
scheduled to receive IV morphine as ordered. Which of the following assessment
findings should be a concern for the nurse?
A. Blood pressure: 88/52 mm Hg
B. Client reports of passing stool once in 7 days
C. Respiratory rate: 14 breaths per minute
D. SpO₂: 98% on room air
, 4|Page
Correct Answer: A
Rationale: Morphine causes vasodilation and can cause hypotension. A BP of
88/52 mm Hg is concerning and should be addressed before administering
morphine .
6. A client receiving a continuous IV heparin infusion for a pulmonary embolism
complains of abdominal pain and black tarry stool. Which of the following should
the nurse anticipate as the next intervention?
A. Administer protamine sulfate as ordered
B. Monitor aPTT
C. Monitor PTT
D. Administer Vitamin K as ordered
Correct Answer: A
Rationale: Black tarry stool indicates gastrointestinal bleeding from heparin.
Protamine sulfate is the antidote for heparin and should be administered as
ordered .
7. The nurse is assigned to four clients. Which of the following clients should the
nurse assess first?
