NUR 265 Exam 2 | two updated Versions |
Questions and Answers | 2026 Update | 100%
Correct
1. The nurse is caring for a client with ARDS. Which assessment finding
indicates the need for immediate intervention?
• A. PaO₂ of 65 mmHg on FiO₂ of 0.4
• B. Respiratory rate of 22 breaths/min
• C. Crackles heard in the lung bases
• D. PaO₂ of 50 mmHg on FiO₂ of 0.6
Correct ,,,,answer,,,,: D
Rationale: A PaO₂ < 60 mmHg on FiO₂ ≥ 0.5 indicates refractory hypoxemia, a
hallmark of ARDS. This requires immediate intervention, such as increasing PEEP
or considering prone positioning.
2. A client with a pulmonary embolism reports sudden chest pain and
shortness of breath. Which assessment finding is most consistent with a PE?
• A. Bradycardia and hypotension
• B. Pleuritic chest pain and hemoptysis
• C. Clear breath sounds bilaterally
• D. Normal oxygen saturation
,Correct ,,,,answer,,,,: B
Rationale: Pleuritic chest pain, dyspnea, and hemoptysis are classic signs of a
pulmonary embolism. Tachycardia (not bradycardia) and hypoxia are also
common.
3. The nurse is assessing a client with a chest tube. Which finding indicates a
normal functioning chest tube?
• A. Continuous bubbling in the water seal chamber
• B. Tidaling (fluctuation) in the water seal chamber with respirations
• C. Absence of drainage in the collection chamber
• D. Bubbling in the water seal chamber with coughing
Correct ,,,,answer,,,,: B
Rationale: Tidaling in the water seal chamber is a normal finding that indicates the
chest tube is patent and functioning correctly. Continuous bubbling indicates an air
leak.
4. A client on mechanical ventilation has a sudden drop in oxygen saturation,
absent breath sounds on the right side, and tracheal deviation to the left. The
nurse suspects:
• A. Pulmonary embolism
• B. Tension pneumothorax
• C. Mucus plug
• D. ARDS
,Correct ,,,,answer,,,,: B
Rationale: Sudden hypoxia, absent breath sounds on one side, and tracheal
deviation away from the affected side are classic signs of a tension pneumothorax,
a life-threatening emergency requiring needle decompression.
5. Which intervention is most important for preventing ventilator-associated
pneumonia (VAP)?
• A. Suction the client every 2 hours
• B. Elevate the head of the bed to 30-45 degrees
• C. Administer prophylactic antibiotics
• D. Change the ventilator circuit daily
Correct ,,,,answer,,,,: B
Rationale: Elevating the head of the bed to 30-45 degrees is a key VAP prevention
measure. Other interventions include oral care with chlorhexidine and daily
sedation vacations.
6. A client with ARDS has a PaO₂/FiO₂ (P/F) ratio of 150. The nurse interprets
this as:
• A. Mild ARDS
• B. Moderate ARDS
• C. Severe ARDS
• D. Normal
, Correct ,,,,answer,,,,: B
Rationale: The P/F ratio defines ARDS severity: Mild (200-300), Moderate (100-
200), Severe (< 100). A ratio of 150 indicates moderate ARDS.
7. The nurse is caring for a client with a pulmonary embolism who is receiving
heparin therapy. Which lab value should be monitored closely?
• A. PT/INR
• B. aPTT
• C. Platelet count
• D. Both B and C
Correct ,,,,answer,,,,: D
Rationale: Heparin is monitored by aPTT. Platelet count should also be monitored
to detect heparin-induced thrombocytopenia (HIT).
8. A client with a chest tube has 200 mL of bright red drainage in 2 hours. The
nurse should:
• A. Document the finding
• B. Notify the healthcare provider immediately
• C. Clamp the chest tube
• D. Increase the suction
Correct ,,,,answer,,,,: B
Rationale: Drainage > 100 mL/hr is concerning and may indicate hemorrhage.
This requires immediate reporting to the provider.
Questions and Answers | 2026 Update | 100%
Correct
1. The nurse is caring for a client with ARDS. Which assessment finding
indicates the need for immediate intervention?
• A. PaO₂ of 65 mmHg on FiO₂ of 0.4
• B. Respiratory rate of 22 breaths/min
• C. Crackles heard in the lung bases
• D. PaO₂ of 50 mmHg on FiO₂ of 0.6
Correct ,,,,answer,,,,: D
Rationale: A PaO₂ < 60 mmHg on FiO₂ ≥ 0.5 indicates refractory hypoxemia, a
hallmark of ARDS. This requires immediate intervention, such as increasing PEEP
or considering prone positioning.
2. A client with a pulmonary embolism reports sudden chest pain and
shortness of breath. Which assessment finding is most consistent with a PE?
• A. Bradycardia and hypotension
• B. Pleuritic chest pain and hemoptysis
• C. Clear breath sounds bilaterally
• D. Normal oxygen saturation
,Correct ,,,,answer,,,,: B
Rationale: Pleuritic chest pain, dyspnea, and hemoptysis are classic signs of a
pulmonary embolism. Tachycardia (not bradycardia) and hypoxia are also
common.
3. The nurse is assessing a client with a chest tube. Which finding indicates a
normal functioning chest tube?
• A. Continuous bubbling in the water seal chamber
• B. Tidaling (fluctuation) in the water seal chamber with respirations
• C. Absence of drainage in the collection chamber
• D. Bubbling in the water seal chamber with coughing
Correct ,,,,answer,,,,: B
Rationale: Tidaling in the water seal chamber is a normal finding that indicates the
chest tube is patent and functioning correctly. Continuous bubbling indicates an air
leak.
4. A client on mechanical ventilation has a sudden drop in oxygen saturation,
absent breath sounds on the right side, and tracheal deviation to the left. The
nurse suspects:
• A. Pulmonary embolism
• B. Tension pneumothorax
• C. Mucus plug
• D. ARDS
,Correct ,,,,answer,,,,: B
Rationale: Sudden hypoxia, absent breath sounds on one side, and tracheal
deviation away from the affected side are classic signs of a tension pneumothorax,
a life-threatening emergency requiring needle decompression.
5. Which intervention is most important for preventing ventilator-associated
pneumonia (VAP)?
• A. Suction the client every 2 hours
• B. Elevate the head of the bed to 30-45 degrees
• C. Administer prophylactic antibiotics
• D. Change the ventilator circuit daily
Correct ,,,,answer,,,,: B
Rationale: Elevating the head of the bed to 30-45 degrees is a key VAP prevention
measure. Other interventions include oral care with chlorhexidine and daily
sedation vacations.
6. A client with ARDS has a PaO₂/FiO₂ (P/F) ratio of 150. The nurse interprets
this as:
• A. Mild ARDS
• B. Moderate ARDS
• C. Severe ARDS
• D. Normal
, Correct ,,,,answer,,,,: B
Rationale: The P/F ratio defines ARDS severity: Mild (200-300), Moderate (100-
200), Severe (< 100). A ratio of 150 indicates moderate ARDS.
7. The nurse is caring for a client with a pulmonary embolism who is receiving
heparin therapy. Which lab value should be monitored closely?
• A. PT/INR
• B. aPTT
• C. Platelet count
• D. Both B and C
Correct ,,,,answer,,,,: D
Rationale: Heparin is monitored by aPTT. Platelet count should also be monitored
to detect heparin-induced thrombocytopenia (HIT).
8. A client with a chest tube has 200 mL of bright red drainage in 2 hours. The
nurse should:
• A. Document the finding
• B. Notify the healthcare provider immediately
• C. Clamp the chest tube
• D. Increase the suction
Correct ,,,,answer,,,,: B
Rationale: Drainage > 100 mL/hr is concerning and may indicate hemorrhage.
This requires immediate reporting to the provider.
