NUR 265 Exam 2 – Question Bank| Questions With Verified
Answers And Rationales 2026
Unit: Respiratory Emergencies
1. A client who is 4 days post-operative suddenly develops difficulty breathing
and sharp chest pain. The nurse calls the rapid response team, raises the HOB,
and applies oxygen. What should the nurse do next?
• A. Administer morphine IV push
• B. Auscultate lung sounds and initiate cardiac monitoring
• C. Draw blood for a D-dimer
• D. Prepare the client for a CT scan
• Answer: B. Auscultate lung sounds and initiate cardiac monitoring
• Rationale: After initial stabilization (O2, HOB), the nurse must perform a focused
assessment (lung sounds, hemodynamics) to gather data for the provider and guide
further interventions .
2. Which ABG finding is expected in the early stage of a Pulmonary Embolism
(PE)?
• A. pH 7.25, PaCO2 55, PaO2 60
• B. pH 7.50, PaCO2 32, PaO2 79
• C. pH 7.35, PaCO2 45, PaO2 95
• D. pH 7.40, PaCO2 40, PaO2 85
• Answer: B. pH 7.50, PaCO2 32, PaO2 79
• Rationale: Early PE causes tachypnea/hyperventilation leading to respiratory
alkalosis (low PaCO2, high pH) with mild hypoxemia due to V/Q mismatch .
3. A client on a heparin infusion (Day 10) has a platelet count of 90,000/mm³.
What is the priority action?
• A. Increase the heparin rate
• B. Administer Vitamin K
• C. Stop the heparin and notify the provider
• D. Document as an expected finding
• Answer: C. Stop the heparin and notify the provider
• Rationale: This drop in platelets indicates Heparin-Induced Thrombocytopenia
(HIT) , a pro-thrombotic emergency. Heparin must be stopped immediately .
4. The nurse observes continuous bubbling in the water seal chamber of a chest
tube. What should the nurse do?
, • A. Clamp the chest tube immediately
• B. Notify the provider of an air leak
• C. Increase the suction pressure
• D. Lower the drainage system to the floor
• Answer: B. Notify the provider of an air leak
• Rationale: Continuous bubbling indicates an air leak. Clamping is contraindicated as
it can cause a tension pneumothorax .
5. The nurse notes tracheal deviation in a client receiving mechanical
ventilation with PEEP. What is the priority intervention?
• A. Prepare for needle decompression
• B. Reposition the client to the opposite side
• C. Suction the endotracheal tube
• D. Sedate the client to reduce anxiety
• Answer: A. Prepare for needle decompression
• Rationale: Tracheal deviation indicates a tension pneumothorax, a life-threatening
emergency requiring immediate needle decompression .
6. Which client is at the highest risk for developing ARDS?
• A. A client with asthma
• B. A client with sepsis
• C. A client with myocardial infarction
• D. A client with diabetic ketoacidosis
• Answer: B. A client with sepsis
• Rationale: Sepsis is the most common risk factor for Acute Respiratory Distress
Syndrome (ARDS) due to systemic inflammation causing alveolar capillary leakage .
7. A client with ARDS has a PaO2 of 59 mmHg while receiving 100% FiO2. This
finding indicates:
• A. Expected outcome of ARDS treatment
• B. Refractory hypoxemia
• C. Compensation for metabolic alkalosis
• D. Acute viral pneumonia
• Answer: B. Refractory hypoxemia
• Rationale: A PaO2 < 60 mmHg on 100% oxygen defines refractory hypoxemia, a
hallmark of severe ARDS indicating the alveoli are filled with fluid and cannot
exchange gas .
8. A client is on a ventilator with the settings: SIMV, rate 12, TV 800, FiO2 80%,
PEEP 5. The nurse notes constant, non-productive coughing. What is the
priority action?
Answers And Rationales 2026
Unit: Respiratory Emergencies
1. A client who is 4 days post-operative suddenly develops difficulty breathing
and sharp chest pain. The nurse calls the rapid response team, raises the HOB,
and applies oxygen. What should the nurse do next?
• A. Administer morphine IV push
• B. Auscultate lung sounds and initiate cardiac monitoring
• C. Draw blood for a D-dimer
• D. Prepare the client for a CT scan
• Answer: B. Auscultate lung sounds and initiate cardiac monitoring
• Rationale: After initial stabilization (O2, HOB), the nurse must perform a focused
assessment (lung sounds, hemodynamics) to gather data for the provider and guide
further interventions .
2. Which ABG finding is expected in the early stage of a Pulmonary Embolism
(PE)?
• A. pH 7.25, PaCO2 55, PaO2 60
• B. pH 7.50, PaCO2 32, PaO2 79
• C. pH 7.35, PaCO2 45, PaO2 95
• D. pH 7.40, PaCO2 40, PaO2 85
• Answer: B. pH 7.50, PaCO2 32, PaO2 79
• Rationale: Early PE causes tachypnea/hyperventilation leading to respiratory
alkalosis (low PaCO2, high pH) with mild hypoxemia due to V/Q mismatch .
3. A client on a heparin infusion (Day 10) has a platelet count of 90,000/mm³.
What is the priority action?
• A. Increase the heparin rate
• B. Administer Vitamin K
• C. Stop the heparin and notify the provider
• D. Document as an expected finding
• Answer: C. Stop the heparin and notify the provider
• Rationale: This drop in platelets indicates Heparin-Induced Thrombocytopenia
(HIT) , a pro-thrombotic emergency. Heparin must be stopped immediately .
4. The nurse observes continuous bubbling in the water seal chamber of a chest
tube. What should the nurse do?
, • A. Clamp the chest tube immediately
• B. Notify the provider of an air leak
• C. Increase the suction pressure
• D. Lower the drainage system to the floor
• Answer: B. Notify the provider of an air leak
• Rationale: Continuous bubbling indicates an air leak. Clamping is contraindicated as
it can cause a tension pneumothorax .
5. The nurse notes tracheal deviation in a client receiving mechanical
ventilation with PEEP. What is the priority intervention?
• A. Prepare for needle decompression
• B. Reposition the client to the opposite side
• C. Suction the endotracheal tube
• D. Sedate the client to reduce anxiety
• Answer: A. Prepare for needle decompression
• Rationale: Tracheal deviation indicates a tension pneumothorax, a life-threatening
emergency requiring immediate needle decompression .
6. Which client is at the highest risk for developing ARDS?
• A. A client with asthma
• B. A client with sepsis
• C. A client with myocardial infarction
• D. A client with diabetic ketoacidosis
• Answer: B. A client with sepsis
• Rationale: Sepsis is the most common risk factor for Acute Respiratory Distress
Syndrome (ARDS) due to systemic inflammation causing alveolar capillary leakage .
7. A client with ARDS has a PaO2 of 59 mmHg while receiving 100% FiO2. This
finding indicates:
• A. Expected outcome of ARDS treatment
• B. Refractory hypoxemia
• C. Compensation for metabolic alkalosis
• D. Acute viral pneumonia
• Answer: B. Refractory hypoxemia
• Rationale: A PaO2 < 60 mmHg on 100% oxygen defines refractory hypoxemia, a
hallmark of severe ARDS indicating the alveoli are filled with fluid and cannot
exchange gas .
8. A client is on a ventilator with the settings: SIMV, rate 12, TV 800, FiO2 80%,
PEEP 5. The nurse notes constant, non-productive coughing. What is the
priority action?
