Adult Health II Exam 1
ADULT HEALTH II EXAM 1 NEWEST 2025/2026 WITH COMPLETE
QUESTIONS AND CORRECT ANSWERS |ALREADY GRADED
A+||BRAND NEW VERSION!
A nurse is monitoring a client following a thoracentesis. The nurse should identify
which of the following manifestations as a complication and contact the
provider right away?
A. Serosanguineous drainage from the puncture site
B. Discomfort at the puncture site
C. Increased heart rate
D. Decrease temperature
C. Increased heart rate
Rationale: Clients are at risk for developing pulmonary edema or cardiovascular
distress due mediastinal content shift after the aspiration of a large amount of
fluid from the client's pleural space. Therefore, the client may experience an
increase in heart and respiratory rate, along with
coughing with blood-tinged frothy sputum, and tightness in the chest. These
findings require notification of the provider immediately.
A nurse is caring for a client who has a chest tube in place to a closed chest
drainage system. Which of the following findings should indicate to the nurse
that the clients lung has re-expanded?
A. oxygen saturation of 95%
B. No fluctuations in the water seal chamber
C. No reports of pleuritic chest pain
D. Occasional bubbling in the water-seal chamber
B. No fluctuations in the water seal chamber
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, Adult Health II Exam 1
Rationale: Fluctuation stops when the lung has re-expanded, but the nurse should
check for other indications of re-expansion, such as equal breath sounds
bilaterally, because fluctuation can also stop when the tubing is obstructed, a
dependent loop hangs below the rest of the tubing, or the suction source is not
functioning.
A nurse is caring for a client who has a chest tube in place to a closed chest
drainage system. Which of the following findings should indicate to the nurse
that the client's lung has re-expanded?
A. Oxygen saturation of 95%
B. No fluctuations in the water seal chamber
C. No reports of pleuritic chest pain
D. Occasional bubbling in the water-seal chamber
A. Oxygen saturation of 95%
Rationale: A client can have an oxygen saturation of 95% with or without lung re-
expansion.
A nurse is caring for a client who has a chest tube connected to a closed drainage
system and needs to be transported to the x-ray department. Which of the
following actions should the nurse take?
A. clamp the chest tube prior to transferring the client to a wheelchair
B. Disconnect the chest tube from the drainage system during transport
C. Keep the Drainage system below the level of the client’s chest at all times
D. Empty the collection chamber prior to transport
C. Keep the Drainage system below the level of the client’s chest at all times
Rationale: During transport, the drainage system should be kept below the level
of the client's chest to prevent air and drainage fluid from re-entering the thoracic
cavity.
2|Page
, Adult Health II Exam 1
A nurse is assessing a client who is 1 day postoperative following a lobectomy and
has a chest tube drainage system in place. Which of the following findings
indicates a need for intervention?
A. Chest tube eyelets not visible
B. Continuous bubbling in the suction control chamber
C. Presence of tidal fluctuation in the water seal chamber
D. Development of subcutaneous emphysema
D. Development of subcutaneous emphysema
Rationale: Subcutaneous emphysema is an indication that air is trapped in and
under the skin, which be the result of a pneumothorax and should be reported to
the provider.
A nurse is caring for a client who has just developed a pulmonary
embolism. Which of the following medications should the nurse anticipate
administering?
A. Furosemide
B. Dexamethasone
C. Heparin
D. Atropine
C. Heparin
Rationale: A pulmonary emboli is a condition in which the pulmonary blood flow
is obstructed, resulting in hypoxia and possible death. Most often caused by a
blood clot, treatment such as heparin, an anticoagulant, is used to prevent the
enlargement of the existing clot or formation of new clots.
A nurse is caring for a client who develops a pulmonary embolism. Which of the
following interventions should the nurse implement first?
A. Give morphine IV.
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, Adult Health II Exam 1
B. Administer oxygen therapy.
C. Start an IV infusion of lactated Ringer's.
D. Initiate cardiac monitoring.
B. Administer oxygen therapy.
Rationale: The greatest risk to the safety of a client who has a pulmonary
embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy
should be applied by the nurse using a nasal cannula or mask. Pulse oximetry
should be initiated to monitor oxygen saturation.
A patient is admitted with a chest wound and experiencing extreme dyspnea,
tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area
of the chest. On assessment, you note there is unequal rise and fall of the chest
with absent breath sounds on the left side. You also note a "sucking" sound when
the patient inhales and exhales. The patient's chest x-ray shows a
pneumothorax. What type of pneumothorax is this known as?
A. Closed pneumothorax
B. Open pneumothorax
C. Tension pneumothorax
D. Spontaneous pneumothorax
B. Open pneumothorax
This description is of an open pneumothorax. An open pneumothorax happens
when there is an opening in the chest wall ( from a gun shot, stabbing etc.) that
creates a passage between the outside air and intrapleural space. This allow air to
pass back and forth during inspiration and expiration. The body will shunt air
through the opening in the chest well instead of the trachea (if the opening on the
chest is large enough) which will create a "sucking" sound.
4|Page
ADULT HEALTH II EXAM 1 NEWEST 2025/2026 WITH COMPLETE
QUESTIONS AND CORRECT ANSWERS |ALREADY GRADED
A+||BRAND NEW VERSION!
A nurse is monitoring a client following a thoracentesis. The nurse should identify
which of the following manifestations as a complication and contact the
provider right away?
A. Serosanguineous drainage from the puncture site
B. Discomfort at the puncture site
C. Increased heart rate
D. Decrease temperature
C. Increased heart rate
Rationale: Clients are at risk for developing pulmonary edema or cardiovascular
distress due mediastinal content shift after the aspiration of a large amount of
fluid from the client's pleural space. Therefore, the client may experience an
increase in heart and respiratory rate, along with
coughing with blood-tinged frothy sputum, and tightness in the chest. These
findings require notification of the provider immediately.
A nurse is caring for a client who has a chest tube in place to a closed chest
drainage system. Which of the following findings should indicate to the nurse
that the clients lung has re-expanded?
A. oxygen saturation of 95%
B. No fluctuations in the water seal chamber
C. No reports of pleuritic chest pain
D. Occasional bubbling in the water-seal chamber
B. No fluctuations in the water seal chamber
1|Page
, Adult Health II Exam 1
Rationale: Fluctuation stops when the lung has re-expanded, but the nurse should
check for other indications of re-expansion, such as equal breath sounds
bilaterally, because fluctuation can also stop when the tubing is obstructed, a
dependent loop hangs below the rest of the tubing, or the suction source is not
functioning.
A nurse is caring for a client who has a chest tube in place to a closed chest
drainage system. Which of the following findings should indicate to the nurse
that the client's lung has re-expanded?
A. Oxygen saturation of 95%
B. No fluctuations in the water seal chamber
C. No reports of pleuritic chest pain
D. Occasional bubbling in the water-seal chamber
A. Oxygen saturation of 95%
Rationale: A client can have an oxygen saturation of 95% with or without lung re-
expansion.
A nurse is caring for a client who has a chest tube connected to a closed drainage
system and needs to be transported to the x-ray department. Which of the
following actions should the nurse take?
A. clamp the chest tube prior to transferring the client to a wheelchair
B. Disconnect the chest tube from the drainage system during transport
C. Keep the Drainage system below the level of the client’s chest at all times
D. Empty the collection chamber prior to transport
C. Keep the Drainage system below the level of the client’s chest at all times
Rationale: During transport, the drainage system should be kept below the level
of the client's chest to prevent air and drainage fluid from re-entering the thoracic
cavity.
2|Page
, Adult Health II Exam 1
A nurse is assessing a client who is 1 day postoperative following a lobectomy and
has a chest tube drainage system in place. Which of the following findings
indicates a need for intervention?
A. Chest tube eyelets not visible
B. Continuous bubbling in the suction control chamber
C. Presence of tidal fluctuation in the water seal chamber
D. Development of subcutaneous emphysema
D. Development of subcutaneous emphysema
Rationale: Subcutaneous emphysema is an indication that air is trapped in and
under the skin, which be the result of a pneumothorax and should be reported to
the provider.
A nurse is caring for a client who has just developed a pulmonary
embolism. Which of the following medications should the nurse anticipate
administering?
A. Furosemide
B. Dexamethasone
C. Heparin
D. Atropine
C. Heparin
Rationale: A pulmonary emboli is a condition in which the pulmonary blood flow
is obstructed, resulting in hypoxia and possible death. Most often caused by a
blood clot, treatment such as heparin, an anticoagulant, is used to prevent the
enlargement of the existing clot or formation of new clots.
A nurse is caring for a client who develops a pulmonary embolism. Which of the
following interventions should the nurse implement first?
A. Give morphine IV.
3|Page
, Adult Health II Exam 1
B. Administer oxygen therapy.
C. Start an IV infusion of lactated Ringer's.
D. Initiate cardiac monitoring.
B. Administer oxygen therapy.
Rationale: The greatest risk to the safety of a client who has a pulmonary
embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy
should be applied by the nurse using a nasal cannula or mask. Pulse oximetry
should be initiated to monitor oxygen saturation.
A patient is admitted with a chest wound and experiencing extreme dyspnea,
tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area
of the chest. On assessment, you note there is unequal rise and fall of the chest
with absent breath sounds on the left side. You also note a "sucking" sound when
the patient inhales and exhales. The patient's chest x-ray shows a
pneumothorax. What type of pneumothorax is this known as?
A. Closed pneumothorax
B. Open pneumothorax
C. Tension pneumothorax
D. Spontaneous pneumothorax
B. Open pneumothorax
This description is of an open pneumothorax. An open pneumothorax happens
when there is an opening in the chest wall ( from a gun shot, stabbing etc.) that
creates a passage between the outside air and intrapleural space. This allow air to
pass back and forth during inspiration and expiration. The body will shunt air
through the opening in the chest well instead of the trachea (if the opening on the
chest is large enough) which will create a "sucking" sound.
4|Page
