Exam 2 prep NUR 265 Questions with 100%
Correct Answers
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 assessment
finding requires immediate action by the nurse?
Dry mucous membranes
Rhonchi in upper lobes
Blood-tinged sputum
Constant, nonproductive coughing Correct Answer:
Constant, nonproductive coughing
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?
,Raise the head of bed to high Fowlers
Assess the airway
Suction the client.
Perform chest physiotherapy. Correct Answer: Assess the
airway
A patient with a pleural effusion is scheduled for a
thoracentesis. Which action should the nurse take to
prepare the patient for the procedure?
Position the patient sitting upright on the edge of the
bed and leaning forward.
Start a peripheral IV line to administer 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. Correct Answer: Position the
,patient sitting upright on the edge of the bed and
leaning forward.
A client with a blood sugar of 525 g/dl and potassium
level of 6.8 mEq/L exhibits Kussmaul's respiration,
confusion, and fruity breath. Which of the following
prescriptions would the nurse anticipate:
3% normal saline IV gtt at 25 mLs/hr
Sodium bicarbonate infusion and Regular Insulin gtt
40 mg Furosemide IVP
6L O2 via nasal cannula Correct Answer: Sodium
bicarbonate infusion and Regular Insulin gtt
The nurse palpates the posterior chest while the client
says "99" and notes absent fremitus. Which action should
the nurse take next?
Encourage the client to turn, cough, and deep breathe.
, Palpate the anterior chest and observe for barrel chest.
Review the chest x-ray report for evidence of
pneumonia.
Auscultate anterior and posterior breath sounds
bilaterally. Correct Answer: 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?
Urinary output of 25 mL/hr
Respiratory rate of 30 breaths/min
+2 dependent edema to bilateral extremities
Heart rate of 115 beats/min Correct Answer: Urinary
output of 25 mL/hr
Correct Answers
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 assessment
finding requires immediate action by the nurse?
Dry mucous membranes
Rhonchi in upper lobes
Blood-tinged sputum
Constant, nonproductive coughing Correct Answer:
Constant, nonproductive coughing
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?
,Raise the head of bed to high Fowlers
Assess the airway
Suction the client.
Perform chest physiotherapy. Correct Answer: Assess the
airway
A patient with a pleural effusion is scheduled for a
thoracentesis. Which action should the nurse take to
prepare the patient for the procedure?
Position the patient sitting upright on the edge of the
bed and leaning forward.
Start a peripheral IV line to administer 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. Correct Answer: Position the
,patient sitting upright on the edge of the bed and
leaning forward.
A client with a blood sugar of 525 g/dl and potassium
level of 6.8 mEq/L exhibits Kussmaul's respiration,
confusion, and fruity breath. Which of the following
prescriptions would the nurse anticipate:
3% normal saline IV gtt at 25 mLs/hr
Sodium bicarbonate infusion and Regular Insulin gtt
40 mg Furosemide IVP
6L O2 via nasal cannula Correct Answer: Sodium
bicarbonate infusion and Regular Insulin gtt
The nurse palpates the posterior chest while the client
says "99" and notes absent fremitus. Which action should
the nurse take next?
Encourage the client to turn, cough, and deep breathe.
, Palpate the anterior chest and observe for barrel chest.
Review the chest x-ray report for evidence of
pneumonia.
Auscultate anterior and posterior breath sounds
bilaterally. Correct Answer: 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?
Urinary output of 25 mL/hr
Respiratory rate of 30 breaths/min
+2 dependent edema to bilateral extremities
Heart rate of 115 beats/min Correct Answer: Urinary
output of 25 mL/hr
