NUR-265 EXAM 2
QUESTIONS COVERING CRITICAL
CARE
NURSING TOPICS SUCH AS
CARDIOVASCULAR AND
RESPIRATORY DISORDERS, FLUID
AND ELECTROLYTE BALANCE
LATEST EXAM UPDATE
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 - CORRECT
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ANSWER✔✔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
c) Level of orientation
d) Skin and mucous membranes - CORRECT
ANSWER✔✔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
,0) Decreased tactile
fremitus | c) RR: 25, 02
saturation of 91%
d) Paradoxical chest movement - CORRECT
ANSWER✔✔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. - CORRECT ANSWER✔✔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
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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.
b) Hyperoxygenate the client with 100% FIO2
c) Assess placement of the endotracheal (ET) tube at lip.
d) Turn the client to right side lying position - CORRECT
ANSWER✔✔Assess placement of the endotracheal (ET)
tube at lip.
A nurse plans care for a client with Cushing's disease. Which
action should the nurse include in the plan of care to prevent
injury?
a) Use a lift sheet to change the client's position
b) Pad the bed rails
c) Keep suctioning equipment at the client's bedside
d) Maintain head of bed at 45° - CORRECT
ANSWER✔✔Maintain head of bed at 45°
QUESTIONS COVERING CRITICAL
CARE
NURSING TOPICS SUCH AS
CARDIOVASCULAR AND
RESPIRATORY DISORDERS, FLUID
AND ELECTROLYTE BALANCE
LATEST EXAM UPDATE
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 - CORRECT
Page 1 of 56
,2 | Page
ANSWER✔✔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
c) Level of orientation
d) Skin and mucous membranes - CORRECT
ANSWER✔✔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
,0) Decreased tactile
fremitus | c) RR: 25, 02
saturation of 91%
d) Paradoxical chest movement - CORRECT
ANSWER✔✔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. - CORRECT ANSWER✔✔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
Page 3 of 56
, 4 | Page
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.
b) Hyperoxygenate the client with 100% FIO2
c) Assess placement of the endotracheal (ET) tube at lip.
d) Turn the client to right side lying position - CORRECT
ANSWER✔✔Assess placement of the endotracheal (ET)
tube at lip.
A nurse plans care for a client with Cushing's disease. Which
action should the nurse include in the plan of care to prevent
injury?
a) Use a lift sheet to change the client's position
b) Pad the bed rails
c) Keep suctioning equipment at the client's bedside
d) Maintain head of bed at 45° - CORRECT
ANSWER✔✔Maintain head of bed at 45°
