EXAM 2 PREP NUR 265 LATEST EXAM
QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS (GRADED A+)
Question: 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?
Answer: ✔✔ Constant, nonproductive coughing
(Rationale: Continuous, ineffective coughing can indicate tracheostomy tube
displacement, carinal irritation, or severe airway obstruction, which places the
client at immediate risk of respiratory failure.)
Question: While monitoring a client with Acute Respiratory Distress Syndrome
(ARDS) on mechanical ventilation, the nurse notes that the peak inspiratory
pressure (PIP) alarm activates with every delivered breath. What is the nurse's best
initial action?
Answer: ✔✔ Assess the airway
(Rationale: Alarms must always be investigated by evaluating the patient first.
Assessing the airway allows the nurse to identify the specific root cause, such as an
ETT kink, patient biting, or fluid accumulation, before choosing an intervention
like suctioning.)
Question: A patient diagnosed with a large pleural effusion is prepared for an
ultrasound-guided thoracentesis at the bedside. How should the nurse position the
patient to facilitate optimal access to the pleural space?
Answer: ✔✔ Position the patient sitting upright on the edge of the bed and leaning
forward over an overbed table.
(Rationale: This specific position spreads the intercostal spaces wider and allows
the fluid to pool at the base of the pleural cavity, maximizing safety and fluid
clearance during needle insertion.)
Question: A patient presents with a serum glucose of 525mg/dL and a potassium
level of 6.8 mEq. The nurse notes deep, rapid Kussmaul's respirations, altered
,orientation, and a distinctly fruity odor to the breath. Which medical prescription
should the nurse anticipate?
Answer: ✔✔ Sodium bicarbonate infusion and Regular Insulin infusion
(Rationale: This client is exhibiting classic signs of severe Diabetic Ketoacidosis
(DKA) with secondary hyperkalemia. An intravenous regular insulin drip will
drive glucose down and push potassium back into the intracellular space, while a
bicarbonate infusion corrects severe metabolic acidosis.)
Question: While performing a posterior chest assessment, the nurse notes an
absolute absence of tactile fremitus while the client repeats the word "99." What is
the nurse's most appropriate next step?
Answer: ✔✔ Auscultate anterior and posterior breath sounds bilaterally.
(Rationale: Absent tactile fremitus occurs when sound vibrations are blocked, such
as in pneumothorax or pleural effusion. The nurse must immediately perform
auscultation to verify bilateral air entry and assess for diminished or absent lung
sounds.)
Question: A nurse is managing a client with a massive pulmonary embolism who
has developed secondary right-sided heart failure. Which new clinical finding
requires the most rapid medical follow-up?
Answer: ✔✔ Urine output of $25\text{ mL/hr}$
(Rationale: A drop in urine output below $30\text{ mL/hr}$ indicates inadequate
systemic tissue perfusion and renal hypoperfusion due to severe cardiogenic shock
or systemic hypotension.)
Question: Following a change-of-shift report, which of these four assigned clients
must the nurse physically assess first?
Answer: ✔✔ A client receiving mechanical ventilation via endotracheal tube
whose high-pressure alarm is sounding and who has copious secretions visible.
(Rationale: This represents an immediate threat to the airway and ventilation.
Excessive secretions triggering a high-pressure alarm can rapidly lead to hypoxia
if left un-suctioned.)
, 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.
QUESTIONS AND ANSWERS WITH
COMPLETE SOLUTIONS (GRADED A+)
Question: 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?
Answer: ✔✔ Constant, nonproductive coughing
(Rationale: Continuous, ineffective coughing can indicate tracheostomy tube
displacement, carinal irritation, or severe airway obstruction, which places the
client at immediate risk of respiratory failure.)
Question: While monitoring a client with Acute Respiratory Distress Syndrome
(ARDS) on mechanical ventilation, the nurse notes that the peak inspiratory
pressure (PIP) alarm activates with every delivered breath. What is the nurse's best
initial action?
Answer: ✔✔ Assess the airway
(Rationale: Alarms must always be investigated by evaluating the patient first.
Assessing the airway allows the nurse to identify the specific root cause, such as an
ETT kink, patient biting, or fluid accumulation, before choosing an intervention
like suctioning.)
Question: A patient diagnosed with a large pleural effusion is prepared for an
ultrasound-guided thoracentesis at the bedside. How should the nurse position the
patient to facilitate optimal access to the pleural space?
Answer: ✔✔ Position the patient sitting upright on the edge of the bed and leaning
forward over an overbed table.
(Rationale: This specific position spreads the intercostal spaces wider and allows
the fluid to pool at the base of the pleural cavity, maximizing safety and fluid
clearance during needle insertion.)
Question: A patient presents with a serum glucose of 525mg/dL and a potassium
level of 6.8 mEq. The nurse notes deep, rapid Kussmaul's respirations, altered
,orientation, and a distinctly fruity odor to the breath. Which medical prescription
should the nurse anticipate?
Answer: ✔✔ Sodium bicarbonate infusion and Regular Insulin infusion
(Rationale: This client is exhibiting classic signs of severe Diabetic Ketoacidosis
(DKA) with secondary hyperkalemia. An intravenous regular insulin drip will
drive glucose down and push potassium back into the intracellular space, while a
bicarbonate infusion corrects severe metabolic acidosis.)
Question: While performing a posterior chest assessment, the nurse notes an
absolute absence of tactile fremitus while the client repeats the word "99." What is
the nurse's most appropriate next step?
Answer: ✔✔ Auscultate anterior and posterior breath sounds bilaterally.
(Rationale: Absent tactile fremitus occurs when sound vibrations are blocked, such
as in pneumothorax or pleural effusion. The nurse must immediately perform
auscultation to verify bilateral air entry and assess for diminished or absent lung
sounds.)
Question: A nurse is managing a client with a massive pulmonary embolism who
has developed secondary right-sided heart failure. Which new clinical finding
requires the most rapid medical follow-up?
Answer: ✔✔ Urine output of $25\text{ mL/hr}$
(Rationale: A drop in urine output below $30\text{ mL/hr}$ indicates inadequate
systemic tissue perfusion and renal hypoperfusion due to severe cardiogenic shock
or systemic hypotension.)
Question: Following a change-of-shift report, which of these four assigned clients
must the nurse physically assess first?
Answer: ✔✔ A client receiving mechanical ventilation via endotracheal tube
whose high-pressure alarm is sounding and who has copious secretions visible.
(Rationale: This represents an immediate threat to the airway and ventilation.
Excessive secretions triggering a high-pressure alarm can rapidly lead to hypoxia
if left un-suctioned.)
, 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.
