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NURS 2243 FINAL EXAM 2025/2026
A client arrives in the emergency department with multiple crushing wounds of the chest,
abdomen, and legs. Which are the priority nursing assessments? - Correct Quality of
respirations and presence of pulses
A client is extubated in the postanesthesia care unit after surgery. For which common
response should the nurse be alert when monitoring the client for acute respiratory distress? -
Correct Restlessness
What order would the nurse follow for the assessment of the pharynx in a client with a
respiratory disorder? - Correct 1.
Inspect the mouth.
Observe the rise and fall of the soft palate.
Assess the symmetry of enlarged tonsils, if present.
Inspect the neck symmetry.
Palpate the lymph nodes.
The nurse is providing postoperative care to a client with lung cancer who had a partial
pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue
around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles
can be felt. How does the nurse describe this assessment finding? - Correct
Subcutaneous emphysema
A nurse is caring for a group of clients on a medical-surgical unit. Which client has the
highest risk for developing a pulmonary embolism? - Correct An obese client with leg
trauma
Besides providing reassurance, what should nursing interventions for a client who is
hyperventilating be focused on? - Correct Having the client breathe into a paper bag
, Page |2
When providing discharge teaching for a young female client who had a pneumothorax, it is
important that the nurse include the signs and symptoms of a recurring pneumothorax. What
is the most important symptom that the nurse should teach the client to report to the
healthcare provider? - Correct Severe shortness of breath
During admission a client appears anxious and says to the nurse, "The doctor told me I have
lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best
response? - Correct "You seem concerned about your diagnosis."
After surgery, a client reports sudden severe chest pain and begins coughing. The nurse
suspects the client has a thromboembolism. What characteristic of the sputum supports the
nurse's suspicion that the client has a pulmonary embolus? - Correct pink
A client is experiencing severe respiratory distress. Which response should the nurse expect
the client to exhibit? - Correct tachycardia
What is the normal value of inspiratory reserve volume? - Correct 3.0 L
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive
pulmonary disease (COPD). By administering a low concentration of oxygen to this client,
the nurse is preventing which physiologic response? - Correct Depression in the
respiratory center
A client is admitted to the postanesthesia care unit after a segmental resection of the right
lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube,
what should the nurse do? - Correct Mark the time and fluid level on the side of the
drainage chamber
A nurse is notified that a victim of a gunshot wound to the right side of the chest is being
transported to the emergency department. To prepare for the client, what is the priority
nursing intervention? - Correct Obtaining equipment for chest tube insertion
The nurse is caring for a client who has a lesion in the right upper lobe. A diagnosis of
tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis? -
Correct Night sweats and blood-tinged sputum
, Page |3
The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral
crackles. Which is the priority nursing intervention? - Correct Place client in a high-
Fowler position
A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning
is necessary, and the nurse follows a specific protocol when performing this procedure. Select
in order of priority the nursing actions that should be taken when suctioning. - Correct
Assess client's vital signs and lung sounds
Activate the ventilator suction hyperoxygenation setting
Insert the catheter without applying suction
Rotate the catheter while suction is applied
In addition to treatment of the underlying cause, which medical intervention should the nurse
anticipate will be included in the management of a client with acute respiratory distress
syndrome (ARDS)? - Correct Positive end-expiratory pressure (PEEP)
A nurse is caring for a client who had a pneumonectomy. Which is the priority nursing
assessment? - Correct Ventilatory exchange
What emergency equipment should the nurse ensure is readily available at the bedside after a
client has surgery for a malignant lesion on a vocal cord? - Correct Tracheostomy set
and oxygen
A nurse is caring for a client in respiratory distress. The healthcare provider prescribes
oxygen via a nonrebreather mask. Which mask should the nurse use to implement the oxygen
prescription? - Correct with bag attached
A client is brought to the emergency department after a bee sting. The client has a history of
allergies to bees and is having difficulty breathing. What client reaction should cause a nurse
the most concern? - Correct Asphyxia
After thoracic surgery, a client has a chest tube connected to a water-seal drainage system that
is attached to suction. When excessive bubbling is observed in the water-seal chamber, what
should the nurse do? - Correct Check the system for air leaks
, Page |4
Which method of oxygen delivery should a nurse anticipate will be prescribed for a client
with a pulse oximetry reading of 65%? - Correct Nonrebreather mask
A nurse works with a large population of immigrant clients and is concerned about the
debilitating effects of influenza. Which action by the nurse is the first line of defense against
an emerging influenza pandemic? - Correct Reporting surveillance findings to
appropriate public health officials
After surgery for cancer of the posterior pharynx, a client is receiving gavage feedings
through a nasogastric tube. A family member asks why this is necessary. What is the nurse's
best response? - Correct "Tube feedings promote healing by reducing the risk for
infection."
A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of
humidified oxygen. What is the primary reason identified by the nurse for suctioning the
client? - Correct The tracheostomy tube interferes with effective coughing.
The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The
client notifies the nurse that the catheter got tangled up in bedclothes and came out. What
should the nurse do first? - Correct Inspect the catheter
To prevent potential aspiration, what technique should a nurse use when cleaning a
tracheostomy tube that has a non-disposable inner cannula? - Correct Apply
precutdressing around the insertion site with the flaps pointing upward.
Two portable drainage catheters with hemovacs attached were placed during a client's
hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed,
the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters.
What is the priority nursing intervention? - Correct Notify the healthcare provider
immediately
A nurse teaches a client scheduled for a tracheostomy about ways to prevent aspiration during
swallowing. Which statement of the client indicates the need for further teaching? - Correct
"I should drink more water and other thin liquids."
NURS 2243 FINAL EXAM 2025/2026
A client arrives in the emergency department with multiple crushing wounds of the chest,
abdomen, and legs. Which are the priority nursing assessments? - Correct Quality of
respirations and presence of pulses
A client is extubated in the postanesthesia care unit after surgery. For which common
response should the nurse be alert when monitoring the client for acute respiratory distress? -
Correct Restlessness
What order would the nurse follow for the assessment of the pharynx in a client with a
respiratory disorder? - Correct 1.
Inspect the mouth.
Observe the rise and fall of the soft palate.
Assess the symmetry of enlarged tonsils, if present.
Inspect the neck symmetry.
Palpate the lymph nodes.
The nurse is providing postoperative care to a client with lung cancer who had a partial
pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue
around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles
can be felt. How does the nurse describe this assessment finding? - Correct
Subcutaneous emphysema
A nurse is caring for a group of clients on a medical-surgical unit. Which client has the
highest risk for developing a pulmonary embolism? - Correct An obese client with leg
trauma
Besides providing reassurance, what should nursing interventions for a client who is
hyperventilating be focused on? - Correct Having the client breathe into a paper bag
, Page |2
When providing discharge teaching for a young female client who had a pneumothorax, it is
important that the nurse include the signs and symptoms of a recurring pneumothorax. What
is the most important symptom that the nurse should teach the client to report to the
healthcare provider? - Correct Severe shortness of breath
During admission a client appears anxious and says to the nurse, "The doctor told me I have
lung cancer. My father died from cancer. I wish I had never smoked." What is the nurse's best
response? - Correct "You seem concerned about your diagnosis."
After surgery, a client reports sudden severe chest pain and begins coughing. The nurse
suspects the client has a thromboembolism. What characteristic of the sputum supports the
nurse's suspicion that the client has a pulmonary embolus? - Correct pink
A client is experiencing severe respiratory distress. Which response should the nurse expect
the client to exhibit? - Correct tachycardia
What is the normal value of inspiratory reserve volume? - Correct 3.0 L
A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive
pulmonary disease (COPD). By administering a low concentration of oxygen to this client,
the nurse is preventing which physiologic response? - Correct Depression in the
respiratory center
A client is admitted to the postanesthesia care unit after a segmental resection of the right
lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube,
what should the nurse do? - Correct Mark the time and fluid level on the side of the
drainage chamber
A nurse is notified that a victim of a gunshot wound to the right side of the chest is being
transported to the emergency department. To prepare for the client, what is the priority
nursing intervention? - Correct Obtaining equipment for chest tube insertion
The nurse is caring for a client who has a lesion in the right upper lobe. A diagnosis of
tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis? -
Correct Night sweats and blood-tinged sputum
, Page |3
The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral
crackles. Which is the priority nursing intervention? - Correct Place client in a high-
Fowler position
A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning
is necessary, and the nurse follows a specific protocol when performing this procedure. Select
in order of priority the nursing actions that should be taken when suctioning. - Correct
Assess client's vital signs and lung sounds
Activate the ventilator suction hyperoxygenation setting
Insert the catheter without applying suction
Rotate the catheter while suction is applied
In addition to treatment of the underlying cause, which medical intervention should the nurse
anticipate will be included in the management of a client with acute respiratory distress
syndrome (ARDS)? - Correct Positive end-expiratory pressure (PEEP)
A nurse is caring for a client who had a pneumonectomy. Which is the priority nursing
assessment? - Correct Ventilatory exchange
What emergency equipment should the nurse ensure is readily available at the bedside after a
client has surgery for a malignant lesion on a vocal cord? - Correct Tracheostomy set
and oxygen
A nurse is caring for a client in respiratory distress. The healthcare provider prescribes
oxygen via a nonrebreather mask. Which mask should the nurse use to implement the oxygen
prescription? - Correct with bag attached
A client is brought to the emergency department after a bee sting. The client has a history of
allergies to bees and is having difficulty breathing. What client reaction should cause a nurse
the most concern? - Correct Asphyxia
After thoracic surgery, a client has a chest tube connected to a water-seal drainage system that
is attached to suction. When excessive bubbling is observed in the water-seal chamber, what
should the nurse do? - Correct Check the system for air leaks
, Page |4
Which method of oxygen delivery should a nurse anticipate will be prescribed for a client
with a pulse oximetry reading of 65%? - Correct Nonrebreather mask
A nurse works with a large population of immigrant clients and is concerned about the
debilitating effects of influenza. Which action by the nurse is the first line of defense against
an emerging influenza pandemic? - Correct Reporting surveillance findings to
appropriate public health officials
After surgery for cancer of the posterior pharynx, a client is receiving gavage feedings
through a nasogastric tube. A family member asks why this is necessary. What is the nurse's
best response? - Correct "Tube feedings promote healing by reducing the risk for
infection."
A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of
humidified oxygen. What is the primary reason identified by the nurse for suctioning the
client? - Correct The tracheostomy tube interferes with effective coughing.
The nurse is caring for a client who has a peripherally inserted central catheter (PICC). The
client notifies the nurse that the catheter got tangled up in bedclothes and came out. What
should the nurse do first? - Correct Inspect the catheter
To prevent potential aspiration, what technique should a nurse use when cleaning a
tracheostomy tube that has a non-disposable inner cannula? - Correct Apply
precutdressing around the insertion site with the flaps pointing upward.
Two portable drainage catheters with hemovacs attached were placed during a client's
hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed,
the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters.
What is the priority nursing intervention? - Correct Notify the healthcare provider
immediately
A nurse teaches a client scheduled for a tracheostomy about ways to prevent aspiration during
swallowing. Which statement of the client indicates the need for further teaching? - Correct
"I should drink more water and other thin liquids."
