NUR104 | NUR104 Medsurg 2 Exam 1 Version 2 |
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is caring for a patient with COPD who is experiencing worsening dyspnea.
Which intervention should the nurse implement first to improve the patient’s
breathing efficiency?
A. Administer a PRN dose of Albuterol
B. Teach the patient pursed-lip breathing
C. Increase the oxygen flow rate to 6 L/min
D. Encourage the patient to cough and deep breathe
Correct Answer: B
Expert Explanation: Pursed-lip breathing is a priority intervention for COPD
patients to prevent airway collapse during expiration. This technique helps to
prolong exhalation and allows for more effective removal of trapped carbon dioxide.
Administering high-flow oxygen can be detrimental as it may suppress the hypoxic
drive in chronic CO2 retainers. Promoting this breathing pattern empowers the
patient to manage acute episodes of shortness of breath. The nurse must prioritize
non-invasive techniques that assist with gas exchange before escalating
pharmacological interventions.
,2. A patient with an acute asthma exacerbation is receiving treatment in the
emergency department. Which finding would most indicate that the patient’s
condition is deteriorating?
A. Silent chest with no audible breath sounds
B. Pulse oximetry reading of 92% on room air
C. Loud wheezing heard on auscultation
D. Respiratory rate of 28 breaths per minute
Correct Answer: A
Expert Explanation: A silent chest is a medical emergency indicating that there is
insufficient air movement to produce wheezing. This suggests severe airway
obstruction and impending respiratory failure. While loud wheezing is concerning,
it indicates that air is still moving through the narrowed airways. A pulse oximetry
of 92% and tachypnea are expected findings in an acute exacerbation but are not
immediately life-threatening. Immediate intubation and aggressive bronchodilation
are typically required for a patient with a silent chest.
3. The nurse is assessing a patient with bacterial pneumonia. Which lung sound is
most likely to be heard over the affected lobe?
A. High-pitched wheezing
B. Stridor during inspiration
,C. Pleural friction rub
D. Fine or coarse crackles
Correct Answer: D
Expert Explanation: Pneumonia involves an inflammatory process where fluid and
exudate fill the alveoli. Crackles occur when air moves through these fluid-filled
spaces during the respiratory cycle. Wheezing is more characteristic of obstructive
diseases like asthma or COPD where airways are constricted. Stridor indicates
upper airway obstruction and is a life-threatening emergency. Proper auscultation
allows the nurse to localize the area of infection and monitor the effectiveness of
antibiotic therapy.
4. A nurse is reviewing the Arterial Blood Gas (ABG) results for a patient in respiratory
failure: pH 7.28, PaCO2 55 mmHg, HCO3 26 mEq/L. How should the nurse interpret
these results?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
, Expert Explanation: A pH of 7.28 indicates acidosis, as it is below the normal range
of 7.35 to 7.45. The PaCO2 of 55 mmHg is elevated, which is the primary cause of the
drop in pH. Since the bicarbonate (HCO3) is within the normal range, the condition
is respiratory in origin and uncompensated. This pattern is commonly seen in
patients with hypoventilation or COPD exacerbations. The nurse must address the
underlying ventilation issue to restore the acid-base balance.
5. A patient with COPD requires low-concentration oxygen therapy. Which delivery
device is most appropriate to ensure a precise FIO2?
A. Simple face mask
B. Nasal cannula
C. Non-rebreather mask
D. Venturi mask
Correct Answer: D
Expert Explanation: The Venturi mask is the most accurate device for delivering a
specific concentration of oxygen. This is particularly important for COPD patients
who may be sensitive to high oxygen levels. Simple masks and nasal cannulas
provide variable concentrations depending on the patient’s inspiratory flow. A non-
rebreather mask is used for high-flow delivery during emergencies. Using a Venturi
Questions with Correct Answers and Expert
Explanation for Each Question | Saint Paul’s School
of Nursing
1. A nurse is caring for a patient with COPD who is experiencing worsening dyspnea.
Which intervention should the nurse implement first to improve the patient’s
breathing efficiency?
A. Administer a PRN dose of Albuterol
B. Teach the patient pursed-lip breathing
C. Increase the oxygen flow rate to 6 L/min
D. Encourage the patient to cough and deep breathe
Correct Answer: B
Expert Explanation: Pursed-lip breathing is a priority intervention for COPD
patients to prevent airway collapse during expiration. This technique helps to
prolong exhalation and allows for more effective removal of trapped carbon dioxide.
Administering high-flow oxygen can be detrimental as it may suppress the hypoxic
drive in chronic CO2 retainers. Promoting this breathing pattern empowers the
patient to manage acute episodes of shortness of breath. The nurse must prioritize
non-invasive techniques that assist with gas exchange before escalating
pharmacological interventions.
,2. A patient with an acute asthma exacerbation is receiving treatment in the
emergency department. Which finding would most indicate that the patient’s
condition is deteriorating?
A. Silent chest with no audible breath sounds
B. Pulse oximetry reading of 92% on room air
C. Loud wheezing heard on auscultation
D. Respiratory rate of 28 breaths per minute
Correct Answer: A
Expert Explanation: A silent chest is a medical emergency indicating that there is
insufficient air movement to produce wheezing. This suggests severe airway
obstruction and impending respiratory failure. While loud wheezing is concerning,
it indicates that air is still moving through the narrowed airways. A pulse oximetry
of 92% and tachypnea are expected findings in an acute exacerbation but are not
immediately life-threatening. Immediate intubation and aggressive bronchodilation
are typically required for a patient with a silent chest.
3. The nurse is assessing a patient with bacterial pneumonia. Which lung sound is
most likely to be heard over the affected lobe?
A. High-pitched wheezing
B. Stridor during inspiration
,C. Pleural friction rub
D. Fine or coarse crackles
Correct Answer: D
Expert Explanation: Pneumonia involves an inflammatory process where fluid and
exudate fill the alveoli. Crackles occur when air moves through these fluid-filled
spaces during the respiratory cycle. Wheezing is more characteristic of obstructive
diseases like asthma or COPD where airways are constricted. Stridor indicates
upper airway obstruction and is a life-threatening emergency. Proper auscultation
allows the nurse to localize the area of infection and monitor the effectiveness of
antibiotic therapy.
4. A nurse is reviewing the Arterial Blood Gas (ABG) results for a patient in respiratory
failure: pH 7.28, PaCO2 55 mmHg, HCO3 26 mEq/L. How should the nurse interpret
these results?
A. Metabolic Acidosis
B. Respiratory Alkalosis
C. Respiratory Acidosis
D. Metabolic Alkalosis
Correct Answer: C
, Expert Explanation: A pH of 7.28 indicates acidosis, as it is below the normal range
of 7.35 to 7.45. The PaCO2 of 55 mmHg is elevated, which is the primary cause of the
drop in pH. Since the bicarbonate (HCO3) is within the normal range, the condition
is respiratory in origin and uncompensated. This pattern is commonly seen in
patients with hypoventilation or COPD exacerbations. The nurse must address the
underlying ventilation issue to restore the acid-base balance.
5. A patient with COPD requires low-concentration oxygen therapy. Which delivery
device is most appropriate to ensure a precise FIO2?
A. Simple face mask
B. Nasal cannula
C. Non-rebreather mask
D. Venturi mask
Correct Answer: D
Expert Explanation: The Venturi mask is the most accurate device for delivering a
specific concentration of oxygen. This is particularly important for COPD patients
who may be sensitive to high oxygen levels. Simple masks and nasal cannulas
provide variable concentrations depending on the patient’s inspiratory flow. A non-
rebreather mask is used for high-flow delivery during emergencies. Using a Venturi
