NUR 265 EXAM 2 LATEST UPDATE 2023-2024COMPLETE
100 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES
The nurse is caring for a client with acute respiratory distress syndrome (ARDS)
who is receiving mechanical ventilation and positive end-expiratory pressure
(PEEP). The alarm sounds, indicating decreased pressure in the system. What is
the nurse's best action?
a. Change the client's position.
b. Suction the client.
c. Assess lung sounds.
d. Turn off the pressure alarm. - ANSWER-ANS: C
One of the biggest risks in the client with ARDS on mechanical ventilation with
PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The
alarms on a ventilator should never be turned off. If the client needed to be
suctioned, the high-pressure alarm would sound. Changing the client's position
would not change the pressure needed to administer a breath.
The nurse is caring for a client receiving heparin and warfarin therapy for a
pulmonary embolus. The client's international normalized ratio (INR) is 2.0. What
is the nurse's best action?
a. Increase the heparin dose.
b. Increase the warfarin dose.
c. Continue the current therapy.
d. Discontinue the heparin. - ANSWER-ANS: D
The client who is being treated for pulmonary embolism usually continues on
heparin and warfarin until the INR reaches a therapeutic level between 2 and 3.
Heparin can then be discontinued because warfarin is therapeutic.
,NUR 265 EXAM 2 LATEST UPDATE 2023-2024COMPLETE
100 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES
The nurse is caring for a postoperative client who suddenly reports difficulty
breathing and sharp chest pain. After notifying the Rapid Response Team, what is
the nurse's priority action?
a. Elevate the head of the bed and apply oxygen.
b. Listen to the client's lung sounds.
c. Pull the call bell out of the wall socket.
d. Assess the client's pulse oximetry. - ANSWER-ANS: A
The client's immediate need is to have oxygen applied. The nurse should then
assess the client's pulse oximetry.
It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic
therapy is initiated. What is the nurse's priority action?
a. Monitor the client's oxygenation.
b. Teach the client about potential side effects.
c. Monitor the IV insertion site.
d. Monitor for bleeding. - ANSWER-ANS: A
Airway and breathing are the top priority. The nurse would also need to monitor
for bleeding when administering fibrinolytic therapy, and would monitor the IV
site as well. Teaching the client is also a need, however. Oxygenation is the
highest priority.
A client with a large pulmonary embolism is receiving alteplase (Activase). The
nurse notes frank red blood in the Foley catheter drainage bag. What is the
nurse's first action?
a. Irrigate the Foley.
b. Administer an antibiotic.
,NUR 265 EXAM 2 LATEST UPDATE 2023-2024COMPLETE
100 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES
c. Clamp the Foley.
d. Notify the health care provider. - ANSWER-ANS: D
Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an
impact on clots outside the pulmonary embolism, and the client is at great risk for
hemorrhage and shock. The nurse should realize the potential for a severe
problem and should call the health care provider immediately for orders. The
other actions would not be appropriate first actions in this situation.
The nurse is caring for a client with a pulmonary embolus who also has right-sided
heart failure. Which symptom will the nurse need to intervene for immediately?
a. Respiratory rate of 28 breaths/min
b. Urinary output of 10 mL/hr
c. Heart rate of 100 beats/min
d. Dry cough - ANSWER-ANS: B
Urinary output is very low; this could indicate that the client has decreased
cardiac output. The nurse will need to intervene and notify the health care
provider. A respiratory rate that is slightly elevated is expected in this condition.
Likewise, a heart rate that is a little higher is expected in this situation. A dry
cough is also commonly found with pulmonary embolus.
A client states, "At night, I usually need to sleep propped up on two pillows in the
chair, but now it seems I need three pillows." What is the nurse's best response?
a. "You should try to rest more during the day."
b. "You should try to lie flat for short periods of time."
c. "You need to stay in the hospital for further evaluation."
d. "You can take medication at night so you can sleep." - ANSWER-ANS: C
, NUR 265 EXAM 2 LATEST UPDATE 2023-2024COMPLETE
100 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES
Orthopnea is the sensation of dyspnea or breathlessness in the supine position.
Clients feel that they cannot catch their breath in the supine position and must
rest or sleep in a semi-sitting position by placing pillows behind their backs or by
using a reclining chair. The degree of breathlessness can be measured roughly by
the number of pillows needed to make the client less dyspneic (e.g., one-pillow
orthopnea, two-pillow orthopnea). With a client who has chronic respiratory
problems, a minor increase in dyspnea may indicate a severe respiratory problem.
Respiratory failure is a high risk. This client needs to stay in the hospital to be
evaluated more completely. The client should not be instructed to try to lie flat,
or to take a sleeping pill.
A client is admitted owing to difficulty breathing. The nurse assesses the client's
color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What
is the nurse's next action?
a. Give an intermittent positive-pressure breathing treatment.
b. Administer a rescue inhaler.
c. Call for a chest x-ray.
d. Assess an arterial blood gas. - ANSWER-ANS: D
When clients with respiratory problems are assessed, an arterial blood gas is
needed for the most accurate assessment of oxygenation. No indications are
known for a breathing treatment or an inhaler, nor does the nurse have enough
information to know whether a chest x-ray is warranted.
A client with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows
a PaO2 of 93 mm Hg. How does the nurse best intervene?
a. Increase the oxygen.
b. Administer an antianxiety medication.
100 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES
The nurse is caring for a client with acute respiratory distress syndrome (ARDS)
who is receiving mechanical ventilation and positive end-expiratory pressure
(PEEP). The alarm sounds, indicating decreased pressure in the system. What is
the nurse's best action?
a. Change the client's position.
b. Suction the client.
c. Assess lung sounds.
d. Turn off the pressure alarm. - ANSWER-ANS: C
One of the biggest risks in the client with ARDS on mechanical ventilation with
PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The
alarms on a ventilator should never be turned off. If the client needed to be
suctioned, the high-pressure alarm would sound. Changing the client's position
would not change the pressure needed to administer a breath.
The nurse is caring for a client receiving heparin and warfarin therapy for a
pulmonary embolus. The client's international normalized ratio (INR) is 2.0. What
is the nurse's best action?
a. Increase the heparin dose.
b. Increase the warfarin dose.
c. Continue the current therapy.
d. Discontinue the heparin. - ANSWER-ANS: D
The client who is being treated for pulmonary embolism usually continues on
heparin and warfarin until the INR reaches a therapeutic level between 2 and 3.
Heparin can then be discontinued because warfarin is therapeutic.
,NUR 265 EXAM 2 LATEST UPDATE 2023-2024COMPLETE
100 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES
The nurse is caring for a postoperative client who suddenly reports difficulty
breathing and sharp chest pain. After notifying the Rapid Response Team, what is
the nurse's priority action?
a. Elevate the head of the bed and apply oxygen.
b. Listen to the client's lung sounds.
c. Pull the call bell out of the wall socket.
d. Assess the client's pulse oximetry. - ANSWER-ANS: A
The client's immediate need is to have oxygen applied. The nurse should then
assess the client's pulse oximetry.
It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic
therapy is initiated. What is the nurse's priority action?
a. Monitor the client's oxygenation.
b. Teach the client about potential side effects.
c. Monitor the IV insertion site.
d. Monitor for bleeding. - ANSWER-ANS: A
Airway and breathing are the top priority. The nurse would also need to monitor
for bleeding when administering fibrinolytic therapy, and would monitor the IV
site as well. Teaching the client is also a need, however. Oxygenation is the
highest priority.
A client with a large pulmonary embolism is receiving alteplase (Activase). The
nurse notes frank red blood in the Foley catheter drainage bag. What is the
nurse's first action?
a. Irrigate the Foley.
b. Administer an antibiotic.
,NUR 265 EXAM 2 LATEST UPDATE 2023-2024COMPLETE
100 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES
c. Clamp the Foley.
d. Notify the health care provider. - ANSWER-ANS: D
Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an
impact on clots outside the pulmonary embolism, and the client is at great risk for
hemorrhage and shock. The nurse should realize the potential for a severe
problem and should call the health care provider immediately for orders. The
other actions would not be appropriate first actions in this situation.
The nurse is caring for a client with a pulmonary embolus who also has right-sided
heart failure. Which symptom will the nurse need to intervene for immediately?
a. Respiratory rate of 28 breaths/min
b. Urinary output of 10 mL/hr
c. Heart rate of 100 beats/min
d. Dry cough - ANSWER-ANS: B
Urinary output is very low; this could indicate that the client has decreased
cardiac output. The nurse will need to intervene and notify the health care
provider. A respiratory rate that is slightly elevated is expected in this condition.
Likewise, a heart rate that is a little higher is expected in this situation. A dry
cough is also commonly found with pulmonary embolus.
A client states, "At night, I usually need to sleep propped up on two pillows in the
chair, but now it seems I need three pillows." What is the nurse's best response?
a. "You should try to rest more during the day."
b. "You should try to lie flat for short periods of time."
c. "You need to stay in the hospital for further evaluation."
d. "You can take medication at night so you can sleep." - ANSWER-ANS: C
, NUR 265 EXAM 2 LATEST UPDATE 2023-2024COMPLETE
100 QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES
Orthopnea is the sensation of dyspnea or breathlessness in the supine position.
Clients feel that they cannot catch their breath in the supine position and must
rest or sleep in a semi-sitting position by placing pillows behind their backs or by
using a reclining chair. The degree of breathlessness can be measured roughly by
the number of pillows needed to make the client less dyspneic (e.g., one-pillow
orthopnea, two-pillow orthopnea). With a client who has chronic respiratory
problems, a minor increase in dyspnea may indicate a severe respiratory problem.
Respiratory failure is a high risk. This client needs to stay in the hospital to be
evaluated more completely. The client should not be instructed to try to lie flat,
or to take a sleeping pill.
A client is admitted owing to difficulty breathing. The nurse assesses the client's
color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What
is the nurse's next action?
a. Give an intermittent positive-pressure breathing treatment.
b. Administer a rescue inhaler.
c. Call for a chest x-ray.
d. Assess an arterial blood gas. - ANSWER-ANS: D
When clients with respiratory problems are assessed, an arterial blood gas is
needed for the most accurate assessment of oxygenation. No indications are
known for a breathing treatment or an inhaler, nor does the nurse have enough
information to know whether a chest x-ray is warranted.
A client with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows
a PaO2 of 93 mm Hg. How does the nurse best intervene?
a. Increase the oxygen.
b. Administer an antianxiety medication.
