Exam 2 prep NUR 265 LATEST EXAM
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A client has a new tracheostomy, on a mechanical ventilator with the following settings: SIMV,
rate of 12, TV 800, FIo2 80% and PEEP of 5 cmH20. Which assessment finding requires
immediate action by the nurse?
Dry mucous membranes
Rhonchi in upper lobes
Blood-tinged sputum
Constant, nonproductive coughing - Answer: Constant, nonproductive coughing
The nurse notes each time the mechanical ventilator delivers a breath to a client with acute
respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the
nurse's best intervention?
Raise the head of bed to high Fowlers
Assess the airway
Suction the client.
Perform chest physiotherapy. - Answer: Assess the airway
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse
take to prepare the patient for the procedure?
, Position the patient sitting upright on the edge of the bed and leaning forward.
Start a peripheral IV line to administer the necessary sedative drugs.
Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.
Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. - Answer:
Position the patient sitting upright on the edge of the bed and leaning forward.
A client with a blood sugar of 525 g/dl and potassium level of 6.8 mEq/L exhibits Kussmaul's
respiration, confusion, and fruity breath. Which of the following prescriptions would the nurse
anticipate:
3% normal saline IV gtt at 25 mLs/hr
Sodium bicarbonate infusion and Regular Insulin gtt
40 mg Furosemide IVP
6L O2 via nasal cannula - Answer: Sodium bicarbonate infusion and Regular Insulin gtt
The nurse palpates the posterior chest while the client says "99" and notes absent fremitus.
Which action should the nurse take next?
Encourage the client to turn, cough, and deep breathe.
Palpate the anterior chest and observe for barrel chest.
Review the chest x-ray report for evidence of pneumonia.
Auscultate anterior and posterior breath sounds bilaterally. - Answer: Auscultate anterior and
posterior breath sounds bilaterally.
The nurse is caring for a client with a pulmonary embolus, also has right-sided heart failure.
Which clinical findings requires immediate follow up?
Review Comprehensive Questions &
Answers. Galen
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WHY STUDENTS CHOOSE US
Professional management of online classes
Support for proctored examinations
Assignment and coursework coordination
Quiz, test and assessment assistance
Fast communication and timely updates
Strict confidentiality and privacy
SERVICES OFFERED
✓Online Class Management
✓Proctored Exam Handling
✓Weekly Discussion Participation
✓Coursework Tracking
✓Academic Scheduling Support
✓Exam Preparation Guidance
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📧 WhatsApp: +254799356524
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EXCELLENCE • EFFICIENCY • CONFIDENTIALITY
A client has a new tracheostomy, on a mechanical ventilator with the following settings: SIMV,
rate of 12, TV 800, FIo2 80% and PEEP of 5 cmH20. Which assessment finding requires
immediate action by the nurse?
Dry mucous membranes
Rhonchi in upper lobes
Blood-tinged sputum
Constant, nonproductive coughing - Answer: Constant, nonproductive coughing
The nurse notes each time the mechanical ventilator delivers a breath to a client with acute
respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the
nurse's best intervention?
Raise the head of bed to high Fowlers
Assess the airway
Suction the client.
Perform chest physiotherapy. - Answer: Assess the airway
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse
take to prepare the patient for the procedure?
, Position the patient sitting upright on the edge of the bed and leaning forward.
Start a peripheral IV line to administer the necessary sedative drugs.
Remove the water pitcher and remind the patient not to eat or drink anything for 6 hours.
Obtain a large collection device to hold 2 to 3 liters of pleural fluid at one time. - Answer:
Position the patient sitting upright on the edge of the bed and leaning forward.
A client with a blood sugar of 525 g/dl and potassium level of 6.8 mEq/L exhibits Kussmaul's
respiration, confusion, and fruity breath. Which of the following prescriptions would the nurse
anticipate:
3% normal saline IV gtt at 25 mLs/hr
Sodium bicarbonate infusion and Regular Insulin gtt
40 mg Furosemide IVP
6L O2 via nasal cannula - Answer: Sodium bicarbonate infusion and Regular Insulin gtt
The nurse palpates the posterior chest while the client says "99" and notes absent fremitus.
Which action should the nurse take next?
Encourage the client to turn, cough, and deep breathe.
Palpate the anterior chest and observe for barrel chest.
Review the chest x-ray report for evidence of pneumonia.
Auscultate anterior and posterior breath sounds bilaterally. - Answer: Auscultate anterior and
posterior breath sounds bilaterally.
The nurse is caring for a client with a pulmonary embolus, also has right-sided heart failure.
Which clinical findings requires immediate follow up?
