NSG 320 EXAM 2
NSG Adult Health Nursing 320 EXAM 2
/NSG320 Exam 2 Actual Exam Newest
2025/2026 With Complete 100 Questions
And Correct Answers |Already Graded
A+||Brand New Version!|
On auscultation, which finding suggests a right pneumothorax?
A-Bilateral inspiratory and expiratory crackles
B-Absence of breaths sound in the right thorax
C-Inspiratory wheezes in the right thorax
D-Bilateral pleural friction rub
- Correct Answer :B-
Absence of breaths sound in the right thorax
In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore,
breath sounds in the affected lung field are absent. None of the other options are associated
with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory
wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.
A male patient is admitted to the health care facility for treatment of chronic obstructive
pulmonary disease. Which nursing diagnosis is most important for this patient?
A-Activity intolerance related to fatigue
B-Anxiety related to actual threat to health status
C-Risk for infection related to retained secretions
D-Impaired gas exchange related to airflow obstruction
- Correct Answer :D-Impaired gas exchange related to airflow obstruction
A patient airway and an adequate breathing pattern are the top priority for any patient, making
"impaired gas exchange related to airflow obstruction" the most important nursing diagnosis.
The other options also may apply to this patient but less important.
After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage.
When caring for this patient, the nurse must:
A-Monitor fluctuations in the water-seal chamber
B-Clamp the chest tube once every shift
C-Encourage coughing and deep breathing
A+ TEST BANK 1
, NSG 320 EXAM 2
D-Milk the chest tube every 2 hours
- Correct Answer :C-Encourage coughing and deep breathing
When caring for a patient who is recovering from a pneumonectomy, the nurse should
encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because
the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is
not the purpose of chest tube. Chest tube milking is controversial and should be done only to
remove blood clots that obstruct the flow of drainage.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
A-Drawing blood for a hematocrit and hemoglobin level
B-Applying a dressing over the wound and taping it on three sides
C-Preparing a chest tube insertion tray
D-Preparing to start an I.V. line
- Correct Answer :B-Applying a dressing over the wound and taping it on three sides
The nurse immediately should apply a dressing over the stab wound and tape it on three sides to
allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an
open chest wound). Only after covering and taping the wound should the nurse draw blood for
laboratory tests, assist with chest tube insertion, and start an I.V. line.
For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action
best promotes adequate gas exchange?
A-Encouraging the patient to drink three glasses of fluid daily
B-Keeping the patient in semi-fowler's position
C-Using a high-flow venturi mask to deliver oxygen as prescribe
D-Administering a sedative, as prescribe
- Correct Answer :C-Using a high-flow venturi mask to deliver oxygen as prescribe
The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the
medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration,
and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To
promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified,
controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily
would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD.
Patients with COPD and respiratory distress should be places in high-Fowler's position and
should not receive sedatives or other drugs that may further depress the respiratory center.
A+ TEST BANK 2
, NSG 320 EXAM 2
For a female patient with chronic obstructive pulmonary disease, which nursing intervention
would help maintain a patent airway?
A-Restricting fluid intake to 1,000 ml per day
B-Enforcing absolute bed rest
C-Teaching the patient how to perform controlled coughing
D-Administering prescribe sedatives regularly and in large amounts
- Correct Answer :C-Teaching the patient how to perform controlled coughing
Controlled coughing helps maintain a patent airway by helping to mobilize and remove
secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy
and mobilize secretions. Bed rest and sedatives may limit the patient's ability to maintain a
patent airway, causing a high risk for infection from pooled secretions.
Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes
continues gentle bubbling in the suction control chamber. What action is appropriate?
A-Do nothing, because this is an expected finding
B-Immediately clamp the chest tube and notify the physician
C-Check for an air leak because the bubbling should be intermittent
D-Increase the suction pressure so that the bubbling becomes vigorous
- Correct Answer :A-Do nothing, because this is an expected finding
Continuous gentle bubbling should be noted in the suction control chamber. Option b is
incorrect. Chest tubes should only be clamped to check for an air leak or when changing
drainage devices (according to agency policy). Option c is incorrect. Bubbling should be
continuous and not intermittent. Option d is incorrect because bubbling should be gentle.
Increasing the suction pressure only increases the rate of evaporation of water in the drainage
system.
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors
the client and notes fluctuation of the fluid level in the water seal chamber after the tube is
inserted. Based on this assessment, which action would be appropriate?
A-Inform the physician
B-Continue to monitor the client
C-Reinforce the occlusive dressing
D-Encourage the client to deep-breathe
- Correct Answer :B-Continue to monitor the client
A+ TEST BANK 3
, NSG 320 EXAM 2
The presence of fluctuation of the fluid level in the water seal chamber indicates a patent
drainage system. With normal breathing, the water level rises with inspiration and falls with
expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is
not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.
Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest
tube accidentally disconnects. The initial nursing action is to:
A-Call the physician
B-Place the tube in bottle of sterile water
C-Immediately replace the chest tube system
D-Place a sterile dressing over the disconnection site
- Correct Answer :B-Place the tube in bottle of sterile water
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile
water held below the level of the chest. The system is replaced if it breaks or cracks or if the
collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent
complications resulting from the disconnection. The physician may need to be notified, but this
is not the initial action.
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the
client to:
A-Exhale slowly
B-Stay very still
C-Inhale and exhale quickly
D-Perform the Valsalva maneuver
- Correct Answer :D-Perform the Valsalva maneuver
When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a
deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is
taped in place. An alternative instruction is to ask the client to take a deep breath and hold the
breath while the tube is removed. Options A, B, and C are incorrect client instructions.
An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest
wall. Which of these signs would indicate the presence of a pneumothorax in this client?
A-A low respiratory rate
B-Diminished breath sounds
C-The presence of a barrel chest
D-A sucking sound at the site of injury
- Correct Answer :B-Diminished breath sounds
A+ TEST BANK 4
NSG Adult Health Nursing 320 EXAM 2
/NSG320 Exam 2 Actual Exam Newest
2025/2026 With Complete 100 Questions
And Correct Answers |Already Graded
A+||Brand New Version!|
On auscultation, which finding suggests a right pneumothorax?
A-Bilateral inspiratory and expiratory crackles
B-Absence of breaths sound in the right thorax
C-Inspiratory wheezes in the right thorax
D-Bilateral pleural friction rub
- Correct Answer :B-
Absence of breaths sound in the right thorax
In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore,
breath sounds in the affected lung field are absent. None of the other options are associated
with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory
wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.
A male patient is admitted to the health care facility for treatment of chronic obstructive
pulmonary disease. Which nursing diagnosis is most important for this patient?
A-Activity intolerance related to fatigue
B-Anxiety related to actual threat to health status
C-Risk for infection related to retained secretions
D-Impaired gas exchange related to airflow obstruction
- Correct Answer :D-Impaired gas exchange related to airflow obstruction
A patient airway and an adequate breathing pattern are the top priority for any patient, making
"impaired gas exchange related to airflow obstruction" the most important nursing diagnosis.
The other options also may apply to this patient but less important.
After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage.
When caring for this patient, the nurse must:
A-Monitor fluctuations in the water-seal chamber
B-Clamp the chest tube once every shift
C-Encourage coughing and deep breathing
A+ TEST BANK 1
, NSG 320 EXAM 2
D-Milk the chest tube every 2 hours
- Correct Answer :C-Encourage coughing and deep breathing
When caring for a patient who is recovering from a pneumonectomy, the nurse should
encourage coughing and deep breathing to prevent pneumonia in the unaffected lung. Because
the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is
not the purpose of chest tube. Chest tube milking is controversial and should be done only to
remove blood clots that obstruct the flow of drainage.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
A-Drawing blood for a hematocrit and hemoglobin level
B-Applying a dressing over the wound and taping it on three sides
C-Preparing a chest tube insertion tray
D-Preparing to start an I.V. line
- Correct Answer :B-Applying a dressing over the wound and taping it on three sides
The nurse immediately should apply a dressing over the stab wound and tape it on three sides to
allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an
open chest wound). Only after covering and taping the wound should the nurse draw blood for
laboratory tests, assist with chest tube insertion, and start an I.V. line.
For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action
best promotes adequate gas exchange?
A-Encouraging the patient to drink three glasses of fluid daily
B-Keeping the patient in semi-fowler's position
C-Using a high-flow venturi mask to deliver oxygen as prescribe
D-Administering a sedative, as prescribe
- Correct Answer :C-Using a high-flow venturi mask to deliver oxygen as prescribe
The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the
medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration,
and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To
promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified,
controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily
would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD.
Patients with COPD and respiratory distress should be places in high-Fowler's position and
should not receive sedatives or other drugs that may further depress the respiratory center.
A+ TEST BANK 2
, NSG 320 EXAM 2
For a female patient with chronic obstructive pulmonary disease, which nursing intervention
would help maintain a patent airway?
A-Restricting fluid intake to 1,000 ml per day
B-Enforcing absolute bed rest
C-Teaching the patient how to perform controlled coughing
D-Administering prescribe sedatives regularly and in large amounts
- Correct Answer :C-Teaching the patient how to perform controlled coughing
Controlled coughing helps maintain a patent airway by helping to mobilize and remove
secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy
and mobilize secretions. Bed rest and sedatives may limit the patient's ability to maintain a
patent airway, causing a high risk for infection from pooled secretions.
Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes
continues gentle bubbling in the suction control chamber. What action is appropriate?
A-Do nothing, because this is an expected finding
B-Immediately clamp the chest tube and notify the physician
C-Check for an air leak because the bubbling should be intermittent
D-Increase the suction pressure so that the bubbling becomes vigorous
- Correct Answer :A-Do nothing, because this is an expected finding
Continuous gentle bubbling should be noted in the suction control chamber. Option b is
incorrect. Chest tubes should only be clamped to check for an air leak or when changing
drainage devices (according to agency policy). Option c is incorrect. Bubbling should be
continuous and not intermittent. Option d is incorrect because bubbling should be gentle.
Increasing the suction pressure only increases the rate of evaporation of water in the drainage
system.
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors
the client and notes fluctuation of the fluid level in the water seal chamber after the tube is
inserted. Based on this assessment, which action would be appropriate?
A-Inform the physician
B-Continue to monitor the client
C-Reinforce the occlusive dressing
D-Encourage the client to deep-breathe
- Correct Answer :B-Continue to monitor the client
A+ TEST BANK 3
, NSG 320 EXAM 2
The presence of fluctuation of the fluid level in the water seal chamber indicates a patent
drainage system. With normal breathing, the water level rises with inspiration and falls with
expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is
not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.
Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest
tube accidentally disconnects. The initial nursing action is to:
A-Call the physician
B-Place the tube in bottle of sterile water
C-Immediately replace the chest tube system
D-Place a sterile dressing over the disconnection site
- Correct Answer :B-Place the tube in bottle of sterile water
If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile
water held below the level of the chest. The system is replaced if it breaks or cracks or if the
collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent
complications resulting from the disconnection. The physician may need to be notified, but this
is not the initial action.
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the
client to:
A-Exhale slowly
B-Stay very still
C-Inhale and exhale quickly
D-Perform the Valsalva maneuver
- Correct Answer :D-Perform the Valsalva maneuver
When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a
deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is
taped in place. An alternative instruction is to ask the client to take a deep breath and hold the
breath while the tube is removed. Options A, B, and C are incorrect client instructions.
An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest
wall. Which of these signs would indicate the presence of a pneumothorax in this client?
A-A low respiratory rate
B-Diminished breath sounds
C-The presence of a barrel chest
D-A sucking sound at the site of injury
- Correct Answer :B-Diminished breath sounds
A+ TEST BANK 4
