NUR 265/ NUR265 Exam 2 – (New 2026/
2027 Update) Advanced Concepts of
Medical-Surgical Nursing Guide|
Questions & Answers | Grade A| 100%
Correct (Verified Solutions)- Galen
EXAM
1. The nurse is caring for a client with status asthmaticus. Which
finding indicates the client is worsening and requires immediate
intervention?
A. Decreased wheezing with absent breath sounds
B. Increased coughing with thick sputum
C. Respiratory rate of 28 breaths per minute
D. Wheezing heard throughout all lung fields
,,,answer,,,,: A. Decreased wheezing with absent breath sounds
Rationale: Status asthmaticus is an asthma emergency not
responding to treatment. The "silent chest" with decreased or
absent wheezing indicates severe airway obstruction with minimal
air movement. This client is at high risk for intubation and
respiratory arrest .
2. The nurse is caring for a client with COPD who has an SpO₂ of
88% on 2 L nasal cannula. The client is alert and oriented. What
action should the nurse take?
,A. Increase oxygen to 4 L nasal cannula
B. Maintain current oxygen flow rate
C. Prepare for intubation
D. Apply a non-rebreather mask
,,,answer,,,,: B. Maintain current oxygen flow rate
Rationale: COPD clients may have a hypoxic drive. Target SpO₂ is
typically 88-92% to prevent respiratory depression from over-
oxygenation. The client is stable and should not have oxygen
increased without an order .
3. The nurse is assessing a client with pneumonia. Which finding
requires immediate intervention?
A. Temperature of 101.2°F (38.4°C)
B. Cough productive of green sputum
C. Respiratory rate of 32 breaths per minute
D. Oxygen saturation of 91% on room air
,,,answer,,,,: C. Respiratory rate of 32 breaths per minute
Rationale: Tachypnea (RR >24) indicates respiratory distress.
While 91% SpO₂ is low, tachypnea with pneumonia suggests
worsening gas exchange and impending respiratory failure,
requiring immediate assessment .
4. The nurse is caring for a client with a chest tube. Which finding
requires immediate intervention?
,A. Tidaling in the water seal chamber
B. Continuous bubbling in the water seal chamber
C. Serosanguineous drainage of 50 mL in 8 hours
D. Client report of pain at insertion site
,,,answer,,,,: B. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling in the water seal chamber indicates
an air leak. Tidaling is expected. Minimal drainage and pain are
expected findings .
5. The nurse is assessing a client with pleurisy. Which pain
description is expected?
A. Dull ache that is constant
B. Sharp, knife-like pain worsened by deep breathing
C. Burning pain that radiates down the arm
D. Cramping pain that comes and goes
,,,answer,,,,: B. Sharp, knife-like pain worsened by deep breathing
Rationale: Pleuritic pain is sharp and worsens with inspiration due
to inflamed pleural surfaces rubbing together. Treatment focuses on
the underlying cause .
6. The nurse is caring for a client with a pulmonary embolism (PE).
Which finding is most concerning?
A. Chest pain rated 6/10
B. Oxygen saturation of 85% on 4 L nasal cannula
, C. Heart rate of 110 bpm
D. Respiratory rate of 24 breaths per minute
,,,answer,,,,: B. Oxygen saturation of 85% on 4 L nasal cannula
Rationale: Hypoxemia despite supplemental oxygen indicates
significant gas exchange impairment and potential hemodynamic
compromise, requiring immediate intervention such as increased
oxygen, intubation, or embolectomy .
7. The nurse is caring for a client with active pulmonary
tuberculosis. Which type of precautions should the nurse
implement?
A. Standard precautions only
B. Contact precautions
C. Airborne precautions
D. Droplet precautions
,,,answer,,,,: C. Airborne precautions
Rationale: Active pulmonary TB requires airborne precautions
because the bacteria are transmitted via small aerosolized particles
that remain airborne. An N95 respirator and negative pressure
room are required .
8. The nurse is educating a client with asthma about trigger
avoidance. Which statement by the client indicates a need for
further teaching?
2027 Update) Advanced Concepts of
Medical-Surgical Nursing Guide|
Questions & Answers | Grade A| 100%
Correct (Verified Solutions)- Galen
EXAM
1. The nurse is caring for a client with status asthmaticus. Which
finding indicates the client is worsening and requires immediate
intervention?
A. Decreased wheezing with absent breath sounds
B. Increased coughing with thick sputum
C. Respiratory rate of 28 breaths per minute
D. Wheezing heard throughout all lung fields
,,,answer,,,,: A. Decreased wheezing with absent breath sounds
Rationale: Status asthmaticus is an asthma emergency not
responding to treatment. The "silent chest" with decreased or
absent wheezing indicates severe airway obstruction with minimal
air movement. This client is at high risk for intubation and
respiratory arrest .
2. The nurse is caring for a client with COPD who has an SpO₂ of
88% on 2 L nasal cannula. The client is alert and oriented. What
action should the nurse take?
,A. Increase oxygen to 4 L nasal cannula
B. Maintain current oxygen flow rate
C. Prepare for intubation
D. Apply a non-rebreather mask
,,,answer,,,,: B. Maintain current oxygen flow rate
Rationale: COPD clients may have a hypoxic drive. Target SpO₂ is
typically 88-92% to prevent respiratory depression from over-
oxygenation. The client is stable and should not have oxygen
increased without an order .
3. The nurse is assessing a client with pneumonia. Which finding
requires immediate intervention?
A. Temperature of 101.2°F (38.4°C)
B. Cough productive of green sputum
C. Respiratory rate of 32 breaths per minute
D. Oxygen saturation of 91% on room air
,,,answer,,,,: C. Respiratory rate of 32 breaths per minute
Rationale: Tachypnea (RR >24) indicates respiratory distress.
While 91% SpO₂ is low, tachypnea with pneumonia suggests
worsening gas exchange and impending respiratory failure,
requiring immediate assessment .
4. The nurse is caring for a client with a chest tube. Which finding
requires immediate intervention?
,A. Tidaling in the water seal chamber
B. Continuous bubbling in the water seal chamber
C. Serosanguineous drainage of 50 mL in 8 hours
D. Client report of pain at insertion site
,,,answer,,,,: B. Continuous bubbling in the water seal chamber
Rationale: Continuous bubbling in the water seal chamber indicates
an air leak. Tidaling is expected. Minimal drainage and pain are
expected findings .
5. The nurse is assessing a client with pleurisy. Which pain
description is expected?
A. Dull ache that is constant
B. Sharp, knife-like pain worsened by deep breathing
C. Burning pain that radiates down the arm
D. Cramping pain that comes and goes
,,,answer,,,,: B. Sharp, knife-like pain worsened by deep breathing
Rationale: Pleuritic pain is sharp and worsens with inspiration due
to inflamed pleural surfaces rubbing together. Treatment focuses on
the underlying cause .
6. The nurse is caring for a client with a pulmonary embolism (PE).
Which finding is most concerning?
A. Chest pain rated 6/10
B. Oxygen saturation of 85% on 4 L nasal cannula
, C. Heart rate of 110 bpm
D. Respiratory rate of 24 breaths per minute
,,,answer,,,,: B. Oxygen saturation of 85% on 4 L nasal cannula
Rationale: Hypoxemia despite supplemental oxygen indicates
significant gas exchange impairment and potential hemodynamic
compromise, requiring immediate intervention such as increased
oxygen, intubation, or embolectomy .
7. The nurse is caring for a client with active pulmonary
tuberculosis. Which type of precautions should the nurse
implement?
A. Standard precautions only
B. Contact precautions
C. Airborne precautions
D. Droplet precautions
,,,answer,,,,: C. Airborne precautions
Rationale: Active pulmonary TB requires airborne precautions
because the bacteria are transmitted via small aerosolized particles
that remain airborne. An N95 respirator and negative pressure
room are required .
8. The nurse is educating a client with asthma about trigger
avoidance. Which statement by the client indicates a need for
further teaching?
