NR224 EXAM 2 LATEST VERSION 2025
QUESTIONS AND DETAILED CORRECT
ANSWERS | ALREADY GRADED A+
A patient is admitted to the emergency department with
suspected carbon monoxide poisoning. Even though the
patient's color is ruddy and not cyanotic, the nurse
understands the patient is at a risk for decreased oxygen-
carrying capacity of blood because carbon monoxide does
which of the following:
a. stimulates hyperventilation, causing respiratory
alkalosis
b. forms a strong bond with hemoglobin, thus preventing
oxygen binding in the lungs
c. stimulates hypoventilation, causing respiratory acidosis
d. causes alveoli to overinflate, leading to atelectasis
Correct Answer b. forms a strong bond with hemoglobin,
thus preventing oxygen binding in the lungs
An 86 yo women is admitted to the unit with chills and a
fever of 104 F. What physiological process explains why
she is at risk for dyspnea?
a. fever increases metabolic demands, requiring increased
oxygen need.
b. blood glucose stores are depleted and the cells do not
have energy to use oxygen.
c. carbon dioxide production increases due to
hyperventilation.
,d. carbon dioxide production decreases due to
hypoventilation. Correct Answer a. fever increases
metabolic demands, requiring increased oxygen need.
A patient is admitted with the diagnosis of severe left-
sided heart failure. What adventitious lung sounds are
expected on auscultation?
a. sonorous wheezes in the left lower lung
b. rhonchi mid sternum
c. crackles only in apex of lungs
d. inspiratory crackles in lung bases Correct Answer d.
inspiratory crackles in lung bases
A patient is admitted with severe lobar pneumonia. Which
of the following assessment findings would indicate that
the patient needs airway suctioning?
a. coughing up sputum occasionally
b. coughing up thin, watery sputum after nebulization
c. decreased ability to clear airway through coughing
d. lung sounds clear only after coughing Correct Answer c.
decreased ability to clear airway through coughing
A patient has been newly diagnosed with chronic lung
disease. In discussing the lung disease with the nurse,
which of the patient's statements would indicate a need for
further education?
a. I'll make sure that I rest between activities so I don't get
so short of breath.
b. I'll practice the pursed-lip breathing technique to
improve my exercise tolerance.
,c. If I have trouble breathing at night, I'll use two or three
pillows to prop up.
d. If I get short of breath, I'll turn up my oxygen level to 6
L/min. Correct Answer d. If I get short of breath, I'll turn up
my oxygen level to 6 L/min.
The nurse assesses a new patient and finds the patient
short of breath with a respiratory rate of 32 and lying
supine in bed. What is the priority nursing action?
a. raise the head of the bed to 45 degrees or higher.
b. get the oxygen saturation with a pulse oximeter.
c. take the blood pressure and respiratory rate.
d. notify the health care provider of the shortness of
breath. Correct Answer a. raise the head of the bed to 45
degrees or higher.
The nurse is caring for a patient who exhibits labored
breathing, is using accessory muscles, and is coughing up
pink frothy sputum. The patient has diminished breath
sounds in bilateral lung bases. What are the priority
nursing assessments for the nurse to perform prior to
notifying the patient's health care provider? Select all that
apply.
a. oxygen saturation levels
b. amount, color, and consistency of sputum production
c. fluid status
d. change in respiratory rate and pattern
e. pain in lower leg Correct Answer a. oxygen saturation
levels
b. amount, color, and consistency of sputum production
d. change in respiratory rate and pattern
, Two hours after surgery, the nurse assesses a patient who
had a chest tube inserted during surgery. There is 200 mL
of dark red drainage in the chest tube at this time. What is
the appropriate action for the nurse to perform?
a. record the amount and continue to monitor drainage
b. notify the physician
c. strip the chest tube starting at the chest
d. increase the suction by 10 mm Hg Correct Answer a.
record the amount and continue to monitor drainage
The nurse is reviewing the results of the patient's
diagnostic testing. Of the following results, the finding that
falls within expected or normal limits is:
a. palpable, elevated hardened area around a tuberculosis
skin testing site
b. sputum for culture and sensitivity identifies
mycobacterium tuberculosis
c. presence of acid-fast bacilli in sputum
d. arterial oxygen tension of 95 mm Hg Correct Answer d.
arterial oxygen tension of 95 mm Hg
A patient is scheduled to have an intravenous pyelogram
(IVP) the next morning. Which nursing measures should
be implemented before the test? Select all that apply.
a. ask the patient about any allergies and reactions.
b. instruct the patient that a full bladder is required for the
test.
c. instruct the patient to save all urine in a special
container.
d. ensure that informed consent has been obtained.
QUESTIONS AND DETAILED CORRECT
ANSWERS | ALREADY GRADED A+
A patient is admitted to the emergency department with
suspected carbon monoxide poisoning. Even though the
patient's color is ruddy and not cyanotic, the nurse
understands the patient is at a risk for decreased oxygen-
carrying capacity of blood because carbon monoxide does
which of the following:
a. stimulates hyperventilation, causing respiratory
alkalosis
b. forms a strong bond with hemoglobin, thus preventing
oxygen binding in the lungs
c. stimulates hypoventilation, causing respiratory acidosis
d. causes alveoli to overinflate, leading to atelectasis
Correct Answer b. forms a strong bond with hemoglobin,
thus preventing oxygen binding in the lungs
An 86 yo women is admitted to the unit with chills and a
fever of 104 F. What physiological process explains why
she is at risk for dyspnea?
a. fever increases metabolic demands, requiring increased
oxygen need.
b. blood glucose stores are depleted and the cells do not
have energy to use oxygen.
c. carbon dioxide production increases due to
hyperventilation.
,d. carbon dioxide production decreases due to
hypoventilation. Correct Answer a. fever increases
metabolic demands, requiring increased oxygen need.
A patient is admitted with the diagnosis of severe left-
sided heart failure. What adventitious lung sounds are
expected on auscultation?
a. sonorous wheezes in the left lower lung
b. rhonchi mid sternum
c. crackles only in apex of lungs
d. inspiratory crackles in lung bases Correct Answer d.
inspiratory crackles in lung bases
A patient is admitted with severe lobar pneumonia. Which
of the following assessment findings would indicate that
the patient needs airway suctioning?
a. coughing up sputum occasionally
b. coughing up thin, watery sputum after nebulization
c. decreased ability to clear airway through coughing
d. lung sounds clear only after coughing Correct Answer c.
decreased ability to clear airway through coughing
A patient has been newly diagnosed with chronic lung
disease. In discussing the lung disease with the nurse,
which of the patient's statements would indicate a need for
further education?
a. I'll make sure that I rest between activities so I don't get
so short of breath.
b. I'll practice the pursed-lip breathing technique to
improve my exercise tolerance.
,c. If I have trouble breathing at night, I'll use two or three
pillows to prop up.
d. If I get short of breath, I'll turn up my oxygen level to 6
L/min. Correct Answer d. If I get short of breath, I'll turn up
my oxygen level to 6 L/min.
The nurse assesses a new patient and finds the patient
short of breath with a respiratory rate of 32 and lying
supine in bed. What is the priority nursing action?
a. raise the head of the bed to 45 degrees or higher.
b. get the oxygen saturation with a pulse oximeter.
c. take the blood pressure and respiratory rate.
d. notify the health care provider of the shortness of
breath. Correct Answer a. raise the head of the bed to 45
degrees or higher.
The nurse is caring for a patient who exhibits labored
breathing, is using accessory muscles, and is coughing up
pink frothy sputum. The patient has diminished breath
sounds in bilateral lung bases. What are the priority
nursing assessments for the nurse to perform prior to
notifying the patient's health care provider? Select all that
apply.
a. oxygen saturation levels
b. amount, color, and consistency of sputum production
c. fluid status
d. change in respiratory rate and pattern
e. pain in lower leg Correct Answer a. oxygen saturation
levels
b. amount, color, and consistency of sputum production
d. change in respiratory rate and pattern
, Two hours after surgery, the nurse assesses a patient who
had a chest tube inserted during surgery. There is 200 mL
of dark red drainage in the chest tube at this time. What is
the appropriate action for the nurse to perform?
a. record the amount and continue to monitor drainage
b. notify the physician
c. strip the chest tube starting at the chest
d. increase the suction by 10 mm Hg Correct Answer a.
record the amount and continue to monitor drainage
The nurse is reviewing the results of the patient's
diagnostic testing. Of the following results, the finding that
falls within expected or normal limits is:
a. palpable, elevated hardened area around a tuberculosis
skin testing site
b. sputum for culture and sensitivity identifies
mycobacterium tuberculosis
c. presence of acid-fast bacilli in sputum
d. arterial oxygen tension of 95 mm Hg Correct Answer d.
arterial oxygen tension of 95 mm Hg
A patient is scheduled to have an intravenous pyelogram
(IVP) the next morning. Which nursing measures should
be implemented before the test? Select all that apply.
a. ask the patient about any allergies and reactions.
b. instruct the patient that a full bladder is required for the
test.
c. instruct the patient to save all urine in a special
container.
d. ensure that informed consent has been obtained.
