NUR265 EXAM (LATEST 2025/ 2026 UPDATE) ACTUAL EXAM QUESTIONS AND ANSWERS
PRACTICE QUESTIONS WITH SOLUTIONS NEWEST | ALREADY GRADED A+
Question 1
The nurse is assessing a client suspected of having a pulmonary embolism (PE). Which of the
following respiratory findings is most commonly associated with this condition?
A) Bradycardia
B) Productive cough with yellow sputum
C) Cough
D) Lower extremity edema
E) Bradypnea
Correct Answer: C) Cough
Rationale: A cough is a common clinical manifestation of a pulmonary embolism, often
occurring suddenly. While other signs like tachycardia and tachypnea are more frequent, a
cough (sometimes with hemoptysis) is a recognized finding. Bradycardia is incorrect as
tachycardia typically occurs; yellow sputum suggests infection; and while lower extremity
edema may indicate the DVT that caused the PE, it is not a finding of the PE itself.
Question 2
A 4-day postoperative client suddenly develops difficulty breathing and sharp chest pain. After
calling the Rapid Response Team (RRT) and raising the head of the bed, which actions should
the nurse perform next?
1. Auscultate lung sounds.
2. Initiate continuous cardiac monitoring.
3. Connect the client to a continuous pulse oximeter.
A) 1 only
B) 2 only
C) 3 only
D) 1 and 2 only
E) 1, 2, and 3
Correct Answer: E) 1, 2, and 3
Rationale: In an emergency involving potential respiratory or cardiac distress, the
nurse must gather complete objective data. Auscultating lung sounds helps identify
the location of the problem; cardiac monitoring detects arrhythmias common with
PE; and pulse oximetry monitors oxygenation status during the crisis.
Question 3
The nurse provides discharge teaching to a client with a PE who will be taking warfarin at home.
Which statement indicates the client understands the safety precautions?
A) "I will avoid eating all vegetables rich in vitamin K."
B) "I can stop taking warfarin as soon as I feel better."
C) "I should avoid anything rectally, such as enemas or suppositories."
, 2
D) "I will double my dose if I accidentally miss one."
E) "I will use a firm-bristled toothbrush to clean my teeth."
Correct Answer: C) "I should avoid anything rectally, such as enemas or suppositories."
Rationale: Warfarin is an anticoagulant that increases the risk of bleeding. Rectal insertions
can cause trauma to the sensitive mucosal lining, leading to significant bleeding. Clients
should maintain a consistent (not zero) intake of Vitamin K, never stop the drug abruptly,
and never double a missed dose.
Question 4
Which initial arterial blood gas (ABG) result would the nurse most likely expect in a client who
has just developed a pulmonary embolism?
A) pH = 7.35; PaO2 = 95; PaCO2 = 45; HCO3− = 24
B) pH = 7.50; PaO2 = 79; PaCO2 = 32; HCO3− = 23
C) pH = 7.25; PaO2 = 60; PaCO2 = 55; HCO3− = 25
D) pH = 7.40; PaO2 = 85; PaCO2 = 40; HCO3− = 24
E) pH = 7.48; PaO2 = 98; PaCO2 = 48; HCO3− = 28
Correct Answer: B) pH = 7.50; PaO2 = 79 mm Hg; PaCO2 = 32 mm Hg; HCO3− = 23
Rationale: Initially, a client with a PE will experience tachypnea (rapid breathing) due to
hypoxia and anxiety. This causes them to "blow off" CO2, leading to respiratory alkalosis
(high pH, low PaCO2). The PaO2 will also be decreased due to the ventilation-perfusion
mismatch.
Question 5
The nurse is reviewing the charts of four assigned clients. Which client should the nurse assess
first?
A) A client on a heparin infusion for 10 days with a platelet count of 90,000/mm³
B) A stable client on postoperative day 4 reporting mild pain
C) A client with hypertension that is well-controlled with oral medications
D) A client with mild anemia awaiting a scheduled blood draw
E) A client with COPD and an O2 saturation of 91%
Correct Answer: A) Heparin infusion for 10 days with platelet count of 90,000
Rationale: A platelet count below 150,000 (or a 50% drop from baseline) in a client
receiving heparin suggests Heparin-Induced Thrombocytopenia (HIT). This is a life-
threatening immune-mediated reaction that can cause paradoxical thrombosis and requires
immediate cessation of heparin.
Question 6
A nurse is caring for a client with a chest tube. Which finding requires immediate notification of
the primary healthcare provider (PHCP)?
1. Asymmetrical chest expansion.
, 3
2. 100 mL of drainage within one hour.
3. Visibility of the eyelets on the chest tube.
A) 1 only
B) 2 and 3 only
C) 3 only
D) 1, 2, and 3
E) 1 and 2 only
Correct Answer: D) 1, 2, and 3
Rationale: Asymmetrical chest indicates a potential tension pneumothorax or tube
failure; drainage >100 mL/hr suggests active hemorrhage; and seeing the eyelets
means the tube has become dislodged from the pleural space. All three are clinical
emergencies.
Question 7
The nurse observes continuous bubbling in the water seal chamber of a chest tube drainage
system 36 hours after placement for a pneumothorax. What is the nurse's priority action?
A) Clamp the chest tube immediately and leave it clamped
B) Inform the primary health care provider that there is a leak in the system
C) Increase the suction pressure on the wall regulator
D) Document the finding as normal for a pneumothorax
E) Stripping the tubing to remove potential clots
Correct Answer: B) Inform the primary health care provider that there is a leak in the
system
Rationale: Intermittent bubbling is expected in a client with a pneumothorax,
but continuous bubbling in the water seal chamber indicates a leak either in the client's
thoracic cavity or the drainage apparatus itself. Clamping is generally avoided unless
checking for a leak per protocol.
Question 8
A client involved in a boating crash 3 hours ago presents with a headache, restlessness, and the
following ABGs: pH 7.28, PaO2 60, PaCO2 52, SaO2 84%. What is the nurse's interpretation?
A) Metabolic alkalosis
B) Acute respiratory failure
C) Chronic respiratory acidosis
D) Sepsis
E) Compensated respiratory alkalosis
Correct Answer: B) Acute respiratory failure
Rationale: Acute respiratory failure is defined by a PaO2 < 60 mmHg and/or a PaCO2 > 45-
50 mmHg with an acidic pH. This client meets both criteria (hypoxemic and hypercapnic
failure) and is showing clinical signs of distress (restlessness, low SaO2).
, 4
Question 9
Which client is at the greatest risk for developing Acute Respiratory Distress Syndrome
(ARDS)?
A) A 21-year-old college student with a history of mild asthma
B) A client with sepsis who is receiving continuous tube feeding
C) A client who had a myocardial infarction 2 days ago
D) A client with stable COPD and baseline 90% O2 saturation
E) A client who is 1-day post-operative for a total hip replacement
Correct Answer: B) Client who has sepsis receiving continuous tube feeding
Rationale: Sepsis is the most common cause of ARDS due to the systemic inflammatory
response that damages the alveolar-capillary membrane. Continuous tube feeding also
increases the risk of aspiration, which is another significant direct lung injury trigger for
ARDS.
Question 10
Appropriate clinical judgment is demonstrated if the nurse initially assesses which of the
following assigned clients?
A) A client with a PaO2 of 80 mm Hg on room air
B) A client with a PaO2 of 59 mm Hg while receiving 100% oxygen
C) A client with normal vital signs and an oxygen saturation of 98%
D) A client with an oxygen saturation of 90% on room air
E) A client with stable asthma reporting a scratchy throat
Correct Answer: B) PaO2 of 59 mm Hg while receiving 100% oxygen
Rationale: This finding represents "refractory hypoxemia," where the arterial oxygen
remains low despite high levels of supplemental oxygen. This is a hallmark sign of ARDS
and indicates a critical failure of gas exchange that requires immediate intervention.
Question 11
Which of the following is a priority nursing action for a client with ARDS who has just been
placed on mechanical ventilation?
A) Initiate prescribed total parenteral nutrition (TPN)
B) Monitor ventilator settings closely and provide sedation as ordered
C) Reposition the client every 4 hours
D) Administer high doses of corticosteroids to reduce inflammation
E) Maintain the client in a completely supine position
Correct Answer: B) Monitor ventilator settings closely and provide sedation as ordered
Rationale: Clients on mechanical ventilation for ARDS often require "lung-protective"
settings and heavy sedation (or paralytics) to prevent "fighting" the ventilator
(asynchrony), which can cause further lung damage (barotrauma).
PRACTICE QUESTIONS WITH SOLUTIONS NEWEST | ALREADY GRADED A+
Question 1
The nurse is assessing a client suspected of having a pulmonary embolism (PE). Which of the
following respiratory findings is most commonly associated with this condition?
A) Bradycardia
B) Productive cough with yellow sputum
C) Cough
D) Lower extremity edema
E) Bradypnea
Correct Answer: C) Cough
Rationale: A cough is a common clinical manifestation of a pulmonary embolism, often
occurring suddenly. While other signs like tachycardia and tachypnea are more frequent, a
cough (sometimes with hemoptysis) is a recognized finding. Bradycardia is incorrect as
tachycardia typically occurs; yellow sputum suggests infection; and while lower extremity
edema may indicate the DVT that caused the PE, it is not a finding of the PE itself.
Question 2
A 4-day postoperative client suddenly develops difficulty breathing and sharp chest pain. After
calling the Rapid Response Team (RRT) and raising the head of the bed, which actions should
the nurse perform next?
1. Auscultate lung sounds.
2. Initiate continuous cardiac monitoring.
3. Connect the client to a continuous pulse oximeter.
A) 1 only
B) 2 only
C) 3 only
D) 1 and 2 only
E) 1, 2, and 3
Correct Answer: E) 1, 2, and 3
Rationale: In an emergency involving potential respiratory or cardiac distress, the
nurse must gather complete objective data. Auscultating lung sounds helps identify
the location of the problem; cardiac monitoring detects arrhythmias common with
PE; and pulse oximetry monitors oxygenation status during the crisis.
Question 3
The nurse provides discharge teaching to a client with a PE who will be taking warfarin at home.
Which statement indicates the client understands the safety precautions?
A) "I will avoid eating all vegetables rich in vitamin K."
B) "I can stop taking warfarin as soon as I feel better."
C) "I should avoid anything rectally, such as enemas or suppositories."
, 2
D) "I will double my dose if I accidentally miss one."
E) "I will use a firm-bristled toothbrush to clean my teeth."
Correct Answer: C) "I should avoid anything rectally, such as enemas or suppositories."
Rationale: Warfarin is an anticoagulant that increases the risk of bleeding. Rectal insertions
can cause trauma to the sensitive mucosal lining, leading to significant bleeding. Clients
should maintain a consistent (not zero) intake of Vitamin K, never stop the drug abruptly,
and never double a missed dose.
Question 4
Which initial arterial blood gas (ABG) result would the nurse most likely expect in a client who
has just developed a pulmonary embolism?
A) pH = 7.35; PaO2 = 95; PaCO2 = 45; HCO3− = 24
B) pH = 7.50; PaO2 = 79; PaCO2 = 32; HCO3− = 23
C) pH = 7.25; PaO2 = 60; PaCO2 = 55; HCO3− = 25
D) pH = 7.40; PaO2 = 85; PaCO2 = 40; HCO3− = 24
E) pH = 7.48; PaO2 = 98; PaCO2 = 48; HCO3− = 28
Correct Answer: B) pH = 7.50; PaO2 = 79 mm Hg; PaCO2 = 32 mm Hg; HCO3− = 23
Rationale: Initially, a client with a PE will experience tachypnea (rapid breathing) due to
hypoxia and anxiety. This causes them to "blow off" CO2, leading to respiratory alkalosis
(high pH, low PaCO2). The PaO2 will also be decreased due to the ventilation-perfusion
mismatch.
Question 5
The nurse is reviewing the charts of four assigned clients. Which client should the nurse assess
first?
A) A client on a heparin infusion for 10 days with a platelet count of 90,000/mm³
B) A stable client on postoperative day 4 reporting mild pain
C) A client with hypertension that is well-controlled with oral medications
D) A client with mild anemia awaiting a scheduled blood draw
E) A client with COPD and an O2 saturation of 91%
Correct Answer: A) Heparin infusion for 10 days with platelet count of 90,000
Rationale: A platelet count below 150,000 (or a 50% drop from baseline) in a client
receiving heparin suggests Heparin-Induced Thrombocytopenia (HIT). This is a life-
threatening immune-mediated reaction that can cause paradoxical thrombosis and requires
immediate cessation of heparin.
Question 6
A nurse is caring for a client with a chest tube. Which finding requires immediate notification of
the primary healthcare provider (PHCP)?
1. Asymmetrical chest expansion.
, 3
2. 100 mL of drainage within one hour.
3. Visibility of the eyelets on the chest tube.
A) 1 only
B) 2 and 3 only
C) 3 only
D) 1, 2, and 3
E) 1 and 2 only
Correct Answer: D) 1, 2, and 3
Rationale: Asymmetrical chest indicates a potential tension pneumothorax or tube
failure; drainage >100 mL/hr suggests active hemorrhage; and seeing the eyelets
means the tube has become dislodged from the pleural space. All three are clinical
emergencies.
Question 7
The nurse observes continuous bubbling in the water seal chamber of a chest tube drainage
system 36 hours after placement for a pneumothorax. What is the nurse's priority action?
A) Clamp the chest tube immediately and leave it clamped
B) Inform the primary health care provider that there is a leak in the system
C) Increase the suction pressure on the wall regulator
D) Document the finding as normal for a pneumothorax
E) Stripping the tubing to remove potential clots
Correct Answer: B) Inform the primary health care provider that there is a leak in the
system
Rationale: Intermittent bubbling is expected in a client with a pneumothorax,
but continuous bubbling in the water seal chamber indicates a leak either in the client's
thoracic cavity or the drainage apparatus itself. Clamping is generally avoided unless
checking for a leak per protocol.
Question 8
A client involved in a boating crash 3 hours ago presents with a headache, restlessness, and the
following ABGs: pH 7.28, PaO2 60, PaCO2 52, SaO2 84%. What is the nurse's interpretation?
A) Metabolic alkalosis
B) Acute respiratory failure
C) Chronic respiratory acidosis
D) Sepsis
E) Compensated respiratory alkalosis
Correct Answer: B) Acute respiratory failure
Rationale: Acute respiratory failure is defined by a PaO2 < 60 mmHg and/or a PaCO2 > 45-
50 mmHg with an acidic pH. This client meets both criteria (hypoxemic and hypercapnic
failure) and is showing clinical signs of distress (restlessness, low SaO2).
, 4
Question 9
Which client is at the greatest risk for developing Acute Respiratory Distress Syndrome
(ARDS)?
A) A 21-year-old college student with a history of mild asthma
B) A client with sepsis who is receiving continuous tube feeding
C) A client who had a myocardial infarction 2 days ago
D) A client with stable COPD and baseline 90% O2 saturation
E) A client who is 1-day post-operative for a total hip replacement
Correct Answer: B) Client who has sepsis receiving continuous tube feeding
Rationale: Sepsis is the most common cause of ARDS due to the systemic inflammatory
response that damages the alveolar-capillary membrane. Continuous tube feeding also
increases the risk of aspiration, which is another significant direct lung injury trigger for
ARDS.
Question 10
Appropriate clinical judgment is demonstrated if the nurse initially assesses which of the
following assigned clients?
A) A client with a PaO2 of 80 mm Hg on room air
B) A client with a PaO2 of 59 mm Hg while receiving 100% oxygen
C) A client with normal vital signs and an oxygen saturation of 98%
D) A client with an oxygen saturation of 90% on room air
E) A client with stable asthma reporting a scratchy throat
Correct Answer: B) PaO2 of 59 mm Hg while receiving 100% oxygen
Rationale: This finding represents "refractory hypoxemia," where the arterial oxygen
remains low despite high levels of supplemental oxygen. This is a hallmark sign of ARDS
and indicates a critical failure of gas exchange that requires immediate intervention.
Question 11
Which of the following is a priority nursing action for a client with ARDS who has just been
placed on mechanical ventilation?
A) Initiate prescribed total parenteral nutrition (TPN)
B) Monitor ventilator settings closely and provide sedation as ordered
C) Reposition the client every 4 hours
D) Administer high doses of corticosteroids to reduce inflammation
E) Maintain the client in a completely supine position
Correct Answer: B) Monitor ventilator settings closely and provide sedation as ordered
Rationale: Clients on mechanical ventilation for ARDS often require "lung-protective"
settings and heavy sedation (or paralytics) to prevent "fighting" the ventilator
(asynchrony), which can cause further lung damage (barotrauma).
