Exam 2 prep NUR 265 LATEST EXAM
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A client has a new tracheostomy, on a
mechanical ventilator with the following
settings: SIMV, rate of 12, TV 800, FIo2
80% and PEEP of 5 cmH20. Which as-
sessment finding requires immediate ac-
tion by the nurse? Constant, nonproductive coughing
Dry mucous membranes
Rhonchi in upper lobes
Blood-tinged sputum
Constant, nonproductive coughing
The nurse notes each time the mechani-
cal 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? Assess the airway
Raise the head of bed to high Fowlers
Assess the airway
Suction the client.
Perform chest physiotherapy.
A patient with a pleural effusion is sched-
uled for a thoracentesis. Which action
should the nurse take to prepare the pa-
tient for the procedure?
Position the patient sitting upright on the
edge of the bed and leaning forward. Position the patient sitting upright on the
Start a peripheral IV line to administer edge of the bed and leaning forward.
the necessary sedative drugs.
Remove the water pitcher and remind
the patient not to eat or drink anything for
6 hours.
Obtain a large collection device to hold 2
to 3 liters of pleural fluid at one time.
A client with a blood sugar of 525 g/dl
and potassium level of 6.8 mEq/L ex-
, Exam 2 prep NUR 265 LATEST EXAM
Study online at https://quizlet.com/_hlzmbz
hibits Kussmaul's respiration, confusion,
and fruity breath. Which of the following
prescriptions would the nurse anticipate:
Sodium bicarbonate infusion and Regu-
3% normal saline IV gtt at 25 mLs/hr
lar Insulin gtt
Sodium bicarbonate infusion and Regu-
lar Insulin gtt
40 mg Furosemide IVP
6L O2 via nasal cannula
The nurse palpates the posterior chest
while the client says "99" and notes ab-
sent fremitus. Which action should the
nurse take next?
Encourage the client to turn, cough, and
Auscultate anterior and posterior breath
deep breathe.
sounds bilaterally.
Palpate the anterior chest and observe
for barrel chest.
Review the chest x-ray report for evi-
dence of pneumonia.
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 re-
quires immediate follow up?
Urinary output of 25 mL/hr
Urinary output of 25 mL/hr
Respiratory rate of 30 breaths/min
+2 dependent edema to bilateral extrem-
ities
Heart rate of 115 beats/min
After receiving change-of-shift report
about the following four clients, which
client should the nurse assess first?
A client with metastatic bone cancer has
a pleural friction rub and pain upon inspi-
, Exam 2 prep NUR 265 LATEST EXAM
Study online at https://quizlet.com/_hlzmbz
ration.
A client receiving mechanical ventilation
via ET tube has the high alarm sounding
and noted with copious secretions.
A client with Diabetes Insipidus whose A client receiving mechanical ventilation
urine output has been 300mLs/hr, and via ET tube has the high alarm sounding
due for a scheduled dose of desmo- and noted with copious secretions.
pressin po.
A client with a right sided hemothorax
and chest tube drainage noted at 50 mL
over the last two hours.
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?
pH 7.31, PaO2 81 mm Hg, PaCO2 50 pH 7.31, PaO2 81 mm Hg, PaCO2 50
mm Hg, and O2 sat 94% mm Hg, and O2 sat 94%
pH 7.35, PaO2 85 mm Hg, PaCO2 45
mm Hg, and O2 sat 95%
pH 7.34, PaO2 82 mm Hg, PaCO2 40
mm Hg, and O2 sat 97%
pH 7.46, PaO2 90 mm Hg, PaCO2 32
mm Hg, and O2 sat 98%
Which is appropriate teaching for the
client with newly diagnosed adrenal in-
sufficiency?
Avoidnace of foods high in tyramine
Symptoms that indicate developing
Symptoms that indicate developing
adrenal crisis
adrenal crisis
The need for avoiding high impact activ-
ities
The necessity for keeping yearly fol-
low-up appointments
When assessing a client who has just
arrived after an automobile accident,
Study online at https://quizlet.com/_hlzmbz
A client has a new tracheostomy, on a
mechanical ventilator with the following
settings: SIMV, rate of 12, TV 800, FIo2
80% and PEEP of 5 cmH20. Which as-
sessment finding requires immediate ac-
tion by the nurse? Constant, nonproductive coughing
Dry mucous membranes
Rhonchi in upper lobes
Blood-tinged sputum
Constant, nonproductive coughing
The nurse notes each time the mechani-
cal 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? Assess the airway
Raise the head of bed to high Fowlers
Assess the airway
Suction the client.
Perform chest physiotherapy.
A patient with a pleural effusion is sched-
uled for a thoracentesis. Which action
should the nurse take to prepare the pa-
tient for the procedure?
Position the patient sitting upright on the
edge of the bed and leaning forward. Position the patient sitting upright on the
Start a peripheral IV line to administer edge of the bed and leaning forward.
the necessary sedative drugs.
Remove the water pitcher and remind
the patient not to eat or drink anything for
6 hours.
Obtain a large collection device to hold 2
to 3 liters of pleural fluid at one time.
A client with a blood sugar of 525 g/dl
and potassium level of 6.8 mEq/L ex-
, Exam 2 prep NUR 265 LATEST EXAM
Study online at https://quizlet.com/_hlzmbz
hibits Kussmaul's respiration, confusion,
and fruity breath. Which of the following
prescriptions would the nurse anticipate:
Sodium bicarbonate infusion and Regu-
3% normal saline IV gtt at 25 mLs/hr
lar Insulin gtt
Sodium bicarbonate infusion and Regu-
lar Insulin gtt
40 mg Furosemide IVP
6L O2 via nasal cannula
The nurse palpates the posterior chest
while the client says "99" and notes ab-
sent fremitus. Which action should the
nurse take next?
Encourage the client to turn, cough, and
Auscultate anterior and posterior breath
deep breathe.
sounds bilaterally.
Palpate the anterior chest and observe
for barrel chest.
Review the chest x-ray report for evi-
dence of pneumonia.
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 re-
quires immediate follow up?
Urinary output of 25 mL/hr
Urinary output of 25 mL/hr
Respiratory rate of 30 breaths/min
+2 dependent edema to bilateral extrem-
ities
Heart rate of 115 beats/min
After receiving change-of-shift report
about the following four clients, which
client should the nurse assess first?
A client with metastatic bone cancer has
a pleural friction rub and pain upon inspi-
, Exam 2 prep NUR 265 LATEST EXAM
Study online at https://quizlet.com/_hlzmbz
ration.
A client receiving mechanical ventilation
via ET tube has the high alarm sounding
and noted with copious secretions.
A client with Diabetes Insipidus whose A client receiving mechanical ventilation
urine output has been 300mLs/hr, and via ET tube has the high alarm sounding
due for a scheduled dose of desmo- and noted with copious secretions.
pressin po.
A client with a right sided hemothorax
and chest tube drainage noted at 50 mL
over the last two hours.
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?
pH 7.31, PaO2 81 mm Hg, PaCO2 50 pH 7.31, PaO2 81 mm Hg, PaCO2 50
mm Hg, and O2 sat 94% mm Hg, and O2 sat 94%
pH 7.35, PaO2 85 mm Hg, PaCO2 45
mm Hg, and O2 sat 95%
pH 7.34, PaO2 82 mm Hg, PaCO2 40
mm Hg, and O2 sat 97%
pH 7.46, PaO2 90 mm Hg, PaCO2 32
mm Hg, and O2 sat 98%
Which is appropriate teaching for the
client with newly diagnosed adrenal in-
sufficiency?
Avoidnace of foods high in tyramine
Symptoms that indicate developing
Symptoms that indicate developing
adrenal crisis
adrenal crisis
The need for avoiding high impact activ-
ities
The necessity for keeping yearly fol-
low-up appointments
When assessing a client who has just
arrived after an automobile accident,
