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NUR 265 EXAM 2 VERIFIED QUESTIONS & 100%
ACCURATE ANSWERS | COMPLETELY
UPDATED 2025–2026 EDITION A+
PERFORMANCE GUARANTEED
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 . - ANSWER: 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 - ANSWER: 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 ?
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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 . - ANSWER: 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 - ANSWER: 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 % - ANSWER:
c ) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
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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 - ANSWER: 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 - ANSWER: 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
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c ) Level of orientation
d ) Skin and mucous membranes - ANSWER: 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 - ANSWER: 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
. - ANSWER: a ) A client with hyperparathyroidism has abdominal pain , nausea .
The nurse auscultates the lungs of a client on SIMV mechanical ventilation and
hears vesicular breath sounds throughout the right side but decreased sounds on the
left side of the chest Which of the following actions should the nurse take next ?
a ) Elevate the head of the bed .
NUR 265 EXAM 2 VERIFIED QUESTIONS & 100%
ACCURATE ANSWERS | COMPLETELY
UPDATED 2025–2026 EDITION A+
PERFORMANCE GUARANTEED
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 . - ANSWER: 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 - ANSWER: 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 ?
,2|Page
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 . - ANSWER: 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 - ANSWER: 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 % - ANSWER:
c ) pH 7.31 , PaO2 81mm Hg , PaCO2 50 mm Hg , and 02 sat 94 %
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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 - ANSWER: 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 - ANSWER: 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
, 4|Page
c ) Level of orientation
d ) Skin and mucous membranes - ANSWER: 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 - ANSWER: 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
. - ANSWER: a ) A client with hyperparathyroidism has abdominal pain , nausea .
The nurse auscultates the lungs of a client on SIMV mechanical ventilation and
hears vesicular breath sounds throughout the right side but decreased sounds on the
left side of the chest Which of the following actions should the nurse take next ?
a ) Elevate the head of the bed .
