Exam 2 prep NUR 265 LATEST EXAM || Questions and Correct
Detailed Answers
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 correct answers 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. correct answers 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. correct answers
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 correct answers 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. correct answers 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?
Urinary output of 25 mL/hr
Respiratory rate of 30 breaths/min
+2 dependent edema to bilateral extremities
Heart rate of 115 beats/min correct answers Urinary output of 25 mL/hr
After receiving change-of-shift report about the following four clients, which client should the
nurse assess first?
, A client with metastatic bone cancer has a pleural friction rub and pain upon inspiration.
A client receiving mechanical ventilation via ET tube has the high alarm sounding and noted
with copious secretions.
A client with Diabetes Insipidus whose urine output has been 300mLs/hr, and due for a
scheduled dose of desmopressin po.
A client with a right sided hemothorax and chest tube drainage noted at 50 mL over the last two
hours. correct answers A client receiving mechanical ventilation via ET tube has the high alarm
sounding and noted with copious secretions.
The nurse has been made aware of the arterial blood gas (ABG) results on four clients. Which
result is most important for the nurse to report immediately to the health care provider?
pH 7.31, PaO2 81 mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% correct answers pH 7.31, PaO2
81 mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
Which is appropriate teaching for the client with newly diagnosed adrenal insufficiency?
Avoidnace of foods high in tyramine
Symptoms that indicate developing adrenal crisis
The need for avoiding high impact activities
The necessity for keeping yearly follow-up appointments correct answers Symptoms that
indicate developing adrenal crisis
When assessing a client who has just arrived after an automobile accident, the emergency
department nurse notes heart rate of 125 bpm and absent breath sounds over the right lung.
Which of the following actions is priority?
Detailed Answers
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 correct answers 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. correct answers 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. correct answers
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 correct answers 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. correct answers 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?
Urinary output of 25 mL/hr
Respiratory rate of 30 breaths/min
+2 dependent edema to bilateral extremities
Heart rate of 115 beats/min correct answers Urinary output of 25 mL/hr
After receiving change-of-shift report about the following four clients, which client should the
nurse assess first?
, A client with metastatic bone cancer has a pleural friction rub and pain upon inspiration.
A client receiving mechanical ventilation via ET tube has the high alarm sounding and noted
with copious secretions.
A client with Diabetes Insipidus whose urine output has been 300mLs/hr, and due for a
scheduled dose of desmopressin po.
A client with a right sided hemothorax and chest tube drainage noted at 50 mL over the last two
hours. correct answers A client receiving mechanical ventilation via ET tube has the high alarm
sounding and noted with copious secretions.
The nurse has been made aware of the arterial blood gas (ABG) results on four clients. Which
result is most important for the nurse to report immediately to the health care provider?
pH 7.31, PaO2 81 mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95%
pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97%
pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% correct answers pH 7.31, PaO2
81 mm Hg, PaCO2 50 mm Hg, and O2 sat 94%
Which is appropriate teaching for the client with newly diagnosed adrenal insufficiency?
Avoidnace of foods high in tyramine
Symptoms that indicate developing adrenal crisis
The need for avoiding high impact activities
The necessity for keeping yearly follow-up appointments correct answers Symptoms that
indicate developing adrenal crisis
When assessing a client who has just arrived after an automobile accident, the emergency
department nurse notes heart rate of 125 bpm and absent breath sounds over the right lung.
Which of the following actions is priority?
