NUR265 Exam 2 Holmes Mock Answered 2024

NUR265 Exam 2 Holmes Mock Answered 2024 Question 1 2 / 2 pts 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? a) Suction the client. b) Perform chest physiotherapy. c) Assess the airway. d) Raise the head of bed to high Fowlers. Question 2 2 / 2 pts 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? a) Blood-tinged sputum b) Rhonchi in upper lobes c) Dry mucous membranes d) Constant, nonproductive coughing Question 3 2 / 2 pts The nurse palpates the posterior chest while the client says “99” and notes absent fremitus. Which action should the nurse take next? a) Encourage the client to turn, cough, and deep breathe. b) Review the chest x-ray report for evidence of pneumonia. c) Auscultate anterior and posterior breath sounds bilaterally. d) Palpate the anterior chest and observe for barrel chest. Question 4 2 / 2 pts The nurse is caring for a client with a pulmonary embolus, also has right-sided heart failure. Which clinical findings requires immediate follow up? a) Heart rate of 115 beats/min b) Respiratory rate of 28 breaths/min c) +2 dependent edema to bilateral extremities d) Urinary output of 25 mL/hr Question 45 2 / 2 pts The cardiac telemetry unit nurse receives status reports from other nursing units about four clients who need cardiac monitoring. Which client should be transferred to the cardiac unit first? a) Client with Graves Disease and a heart rate of 112 b) Client with tetany who has a new order for IV calcium chloride c) Client with Cushing syndrome and a blood glucose of 240 mg/dL d) Client with Addison’s disease who takes hydrocortisone twice daily Question 46 2 / 2 pts Which is appropriate teaching for the client with newly diagnosed adrenal insufficiency? a) Avoidance of foods high in tyramine b) The need for avoiding high impact activities c) Symptoms that indicate developing adrenal crisis d) The necessity for keeping yearly follow-up appointments Question 47 2 / 2 pts After receiving change-of-shift report about the following four clients, which client should the nurse assess first? a) A client receiving mechanical ventilation via ET tube has the high alarm sounding and noted with copious secretions. b) A client with a right sided hemothorax and chest tube drainage noted at 50 mL over the last two hours. c) A client with Diabetes Insipidus whose urine output has been 300mLs/hr, and due for a scheduled dose of desmopressin po. d) A client with metastatic bone cancer has a pleural friction rub and pain upon inspiration. Question 48 2 / 2 pts 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: a) 40 mg Furosemide IVP 3% normal saline b) IV gtt at 25 mLs/hr c) Sodium bicarbonate infusion and Regular Insulin gtt d) 6L O2 via nasal cannula