NUR 265 EXAM Questions And CORRECT
Answers
The nurse notes each time the mechanical ventilator delivers a breath to a client with acute
respiratory distress syndrome ( ARDS ) , the peak inspiratory pressure alarm sounds . What is
the nurse's best intervention ?
a ) Suction the client .
b ) Perform chest physiotherapy
c ) Assess the airway .
d ) Raise the head of bed to high Fowlers . - CORRECT ANSWERS c ) Assess the airway .
A client has a new tracheostomy , on a mechanical ventilator with the following settings : SIMV ,
rate of 12 TV 800 , Flo2 80 % and PEEP of 5 cmH20 Which assessment finding requires
immediate action by the nurse ?
a ) Blood - tinged sputum
b ) Rhonchi in upper lobes
c ) Dry mucous membranes
d ) Constant , nonproductive coughing - CORRECT ANSWERS d ) Constant , nonproductive
coughing
The nurse palpates the posterior chest while the client says " 99 " and notes absent fremitus .
Which action should the nurse take next ?
a ) Encourage the client to turn , cough , and deep breathe
. b ) Review the chest x - ray report for evidence of pneumonia .
c ) Auscultate anterior and posterior breath sounds bilaterally
. d ) Palpate the anterior chest and observe for barrel chest . - CORRECT ANSWERS c)
Auscultate anterior and posterior breath sounds bilaterally .
,The nurse is caring for a client with a pulmonary embolus , also has right - sided heart failure .
Which clinical findings requires immediate follow up ?
a ) Heart rate of 115 beats / min
b ) Respiratory rate of 28 breaths / min
c ) +2 dependent edema to bilateral extremities
d ) Urinary output of 25 mL / hr - CORRECT ANSWERS d ) Urinary output of 25 mL / hr
The nurse has been made aware of the arterial blood gas ( ABG ) results on four clients . Which
result is most important for the nurse to report immediately to the health care provider ?
a ) pH 7.46 , PaO2 90 mm Hg , PaCO2 32 mm Hg , and O2 sat 98 %
b ) pH 7.35 , PaO2 85 mm Hg , PaCO2 45 mm Hg , and O2 sat 95 %
c ) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
d ) pH 7.34 , PaO2 82 mm Hg , PaCO2 40 mm Hg , and O2 sat 97 % - CORRECT ANSWERS c
) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
The nurse monitors a client immediately following a chest tube insertion for a
hemopneumothorax . Which of the following assessment findings requires immediate follow up
?
a ) 400 ml of blood in the collection chamber
b ) Tidaling in the water - seal chamber
c ) Platelet count 151,000 / micro / L
d ) Subcutaneous emphysema at the insertion site - CORRECT ANSWERS a ) 400 ml of
blood in the collection chamber
When assessing a client who has just arrived after an automobile accident , the emergency
department nurse notes heart rate of 125 bpm and absent breath sounds over the right lung .
Which of the following actions is priority ?
a ) Administration of an inhaled bronchodilator
, b ) Insertion of a chest tube with a chest drainage system
c ) Prepare for oral intubation with mechanical ventilation
d ) Send client for a stat CT scan of the thorax - CORRECT ANSWERS b ) Insertion of a chest
tube with a chest drainage system
A nurse assesses a client who is experiencing an acid - base imbalance . The client's arterial
blood gas values are : pH 7.33 , PaO 88 mm Hg , PaCO 38 mm Hg , and HCO 17 mEq / L . Which
assessment would the nurse perform first ?
a ) Cardiac rate and rhythm
b ) Musculoskeletal strength
c ) Level of orientation
d ) Skin and mucous membranes - CORRECT ANSWERS a ) Cardiac rate and rhythm
A client admitted to the emergency department tells the nurse " I was struck in the chest with a
baseball bat " Which of the following clinical assessments requires immediate follow up ?
a ) Heart rate of 112 beats / minute
b ) Decreased tactile fremitus
c ) RR : 25 , 02 saturation of 91 %
d ) Paradoxical chest movement - CORRECT ANSWERS d ) Paradoxical chest movement
The nurse receives change of - shift report on the following four clients . Which client should the
nurse assess first ?
a ) A client with hyperparathyroidism has abdominal pain , nausea .
b ) A client with hypothyroidism reports last bowel movement was three days ago .
c ) A client with three fractured ribs , RR of 22 requesting pain medication .
d ) A client admitted with Addison's Disease complains of dizziness when standing . - CORRECT
ANSWERS a ) A client with hyperparathyroidism has abdominal pain , nausea .
Answers
The nurse notes each time the mechanical ventilator delivers a breath to a client with acute
respiratory distress syndrome ( ARDS ) , the peak inspiratory pressure alarm sounds . What is
the nurse's best intervention ?
a ) Suction the client .
b ) Perform chest physiotherapy
c ) Assess the airway .
d ) Raise the head of bed to high Fowlers . - CORRECT ANSWERS c ) Assess the airway .
A client has a new tracheostomy , on a mechanical ventilator with the following settings : SIMV ,
rate of 12 TV 800 , Flo2 80 % and PEEP of 5 cmH20 Which assessment finding requires
immediate action by the nurse ?
a ) Blood - tinged sputum
b ) Rhonchi in upper lobes
c ) Dry mucous membranes
d ) Constant , nonproductive coughing - CORRECT ANSWERS d ) Constant , nonproductive
coughing
The nurse palpates the posterior chest while the client says " 99 " and notes absent fremitus .
Which action should the nurse take next ?
a ) Encourage the client to turn , cough , and deep breathe
. b ) Review the chest x - ray report for evidence of pneumonia .
c ) Auscultate anterior and posterior breath sounds bilaterally
. d ) Palpate the anterior chest and observe for barrel chest . - CORRECT ANSWERS c)
Auscultate anterior and posterior breath sounds bilaterally .
,The nurse is caring for a client with a pulmonary embolus , also has right - sided heart failure .
Which clinical findings requires immediate follow up ?
a ) Heart rate of 115 beats / min
b ) Respiratory rate of 28 breaths / min
c ) +2 dependent edema to bilateral extremities
d ) Urinary output of 25 mL / hr - CORRECT ANSWERS d ) Urinary output of 25 mL / hr
The nurse has been made aware of the arterial blood gas ( ABG ) results on four clients . Which
result is most important for the nurse to report immediately to the health care provider ?
a ) pH 7.46 , PaO2 90 mm Hg , PaCO2 32 mm Hg , and O2 sat 98 %
b ) pH 7.35 , PaO2 85 mm Hg , PaCO2 45 mm Hg , and O2 sat 95 %
c ) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
d ) pH 7.34 , PaO2 82 mm Hg , PaCO2 40 mm Hg , and O2 sat 97 % - CORRECT ANSWERS c
) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
The nurse monitors a client immediately following a chest tube insertion for a
hemopneumothorax . Which of the following assessment findings requires immediate follow up
?
a ) 400 ml of blood in the collection chamber
b ) Tidaling in the water - seal chamber
c ) Platelet count 151,000 / micro / L
d ) Subcutaneous emphysema at the insertion site - CORRECT ANSWERS a ) 400 ml of
blood in the collection chamber
When assessing a client who has just arrived after an automobile accident , the emergency
department nurse notes heart rate of 125 bpm and absent breath sounds over the right lung .
Which of the following actions is priority ?
a ) Administration of an inhaled bronchodilator
, b ) Insertion of a chest tube with a chest drainage system
c ) Prepare for oral intubation with mechanical ventilation
d ) Send client for a stat CT scan of the thorax - CORRECT ANSWERS b ) Insertion of a chest
tube with a chest drainage system
A nurse assesses a client who is experiencing an acid - base imbalance . The client's arterial
blood gas values are : pH 7.33 , PaO 88 mm Hg , PaCO 38 mm Hg , and HCO 17 mEq / L . Which
assessment would the nurse perform first ?
a ) Cardiac rate and rhythm
b ) Musculoskeletal strength
c ) Level of orientation
d ) Skin and mucous membranes - CORRECT ANSWERS a ) Cardiac rate and rhythm
A client admitted to the emergency department tells the nurse " I was struck in the chest with a
baseball bat " Which of the following clinical assessments requires immediate follow up ?
a ) Heart rate of 112 beats / minute
b ) Decreased tactile fremitus
c ) RR : 25 , 02 saturation of 91 %
d ) Paradoxical chest movement - CORRECT ANSWERS d ) Paradoxical chest movement
The nurse receives change of - shift report on the following four clients . Which client should the
nurse assess first ?
a ) A client with hyperparathyroidism has abdominal pain , nausea .
b ) A client with hypothyroidism reports last bowel movement was three days ago .
c ) A client with three fractured ribs , RR of 22 requesting pain medication .
d ) A client admitted with Addison's Disease complains of dizziness when standing . - CORRECT
ANSWERS a ) A client with hyperparathyroidism has abdominal pain , nausea .
