, NSG 300 Exam 3 – Foundations of Nursing
Actual Questions & Answers (GCU) 100%
Guarantee Pass
Q1. A patient presents with shortness of breath and a respiratory rate of 28. What
is the first nursing action?
A. Administer 2L of Oxygen
B. Elevate the head of the bed (High-Fowler's)
C. Call the healthcare provider
D. Obtain a chest X-ray
Answer: B. Elevate the head of the bed (High-Fowler's)
Rationale: Positioning is the quickest, non-invasive way to promote lung expansion and
ease the work of breathing. High-Fowler's position uses gravity to assist diaphragmatic
movement and lung expansion .
Q2. The nurse is caring for a patient with pneumonia. On entering the room, the
nurse finds the patient lying in bed, coughing, and unable to clear secretions.
What should the nurse do first?
A. Start oxygen at 2 L/min via nasal cannula
B. Elevate the head of the bed at 45 degrees
C. Encourage the patient to use the incentive spirometer
D. Notify the health care provider
Answer: B. Elevate the head of the bed at 45 degrees
Rationale: Positioning the patient upright promotes lung expansion and facilitates
secretion clearance. This is the priority intervention before initiating other measures .
,Q3. Which assessment findings indicate that the patient is experiencing an acute
disturbance in oxygenation and requires immediate intervention? (Select all that
apply)
A. SpO2 value of 95%
B. Retractions
C. Respiratory rate of 28 bpm
D. Nasal flaring
E. Clubbing of fingers
Answer: B, C, & D
Rationale: Retractions, tachypnea (RR >20), and nasal flaring are acute signs of
respiratory distress requiring immediate intervention. Clubbing is a chronic finding.
SpO2 of 95% is within normal range .
Q4. What are the early and late signs of hypoxia?
A. Early: cyanosis; Late: restlessness
B. Early: restlessness and confusion; Late: cyanosis
C. Early: bradycardia; Late: tachypnea
D. Early: euphoria; Late: hypotension
Answer: B. Early: restlessness and confusion; Late: cyanosis
Rationale: Early signs of hypoxia include apprehension, restlessness, and confusion due
to cerebral hypoxia. Cyanosis is a late sign indicating severe hypoxemia .
Q5. A patient with a tracheostomy has thick tenacious secretions. To maintain the
airway, the most appropriate action for the nurse includes:
A. Tracheal suctioning
B. Oropharyngeal suctioning
C. Nasotracheal suctioning
D. Orotracheal suctioning
Answer: A. Tracheal suctioning
, Rationale: For a patient with a tracheostomy, tracheal suctioning is the appropriate
method to remove secretions directly from the artificial airway. Other methods are used
for patients without artificial airways .
Q6. The nurse is preparing to suction a patient's tracheostomy. What is the
maximum time for each suction pass?
A. 5 seconds
B. 10–15 seconds
C. 30 seconds
D. 1 minute
Answer: B. 10–15 seconds
Rationale: Prolonged suctioning causes hypoxia and can trigger vagal stimulation
leading to bradycardia. The maximum suction time is 10-15 seconds per pass .
Q7. Which skills can the nurse delegate to assistive personnel (AP)? (Select all that
apply)
A. Initiate oxygen therapy via nasal cannula
B. Perform nasotracheal suctioning of a patient
C. Educate the patient about the use of an incentive spirometer
D. Assist with care of an established tracheostomy tube
E. Reposition a patient with a chest tube
Answer: D & E
Rationale: AP can assist with established tracheostomy care and reposition patients
with chest tubes. Assessment, initiation of oxygen therapy, and patient education
require RN-level judgment .
Q8. What is the normal range for Oxygen Saturation (SpO2) in a healthy adult?
A. 85–90%
B. 95–100%
Actual Questions & Answers (GCU) 100%
Guarantee Pass
Q1. A patient presents with shortness of breath and a respiratory rate of 28. What
is the first nursing action?
A. Administer 2L of Oxygen
B. Elevate the head of the bed (High-Fowler's)
C. Call the healthcare provider
D. Obtain a chest X-ray
Answer: B. Elevate the head of the bed (High-Fowler's)
Rationale: Positioning is the quickest, non-invasive way to promote lung expansion and
ease the work of breathing. High-Fowler's position uses gravity to assist diaphragmatic
movement and lung expansion .
Q2. The nurse is caring for a patient with pneumonia. On entering the room, the
nurse finds the patient lying in bed, coughing, and unable to clear secretions.
What should the nurse do first?
A. Start oxygen at 2 L/min via nasal cannula
B. Elevate the head of the bed at 45 degrees
C. Encourage the patient to use the incentive spirometer
D. Notify the health care provider
Answer: B. Elevate the head of the bed at 45 degrees
Rationale: Positioning the patient upright promotes lung expansion and facilitates
secretion clearance. This is the priority intervention before initiating other measures .
,Q3. Which assessment findings indicate that the patient is experiencing an acute
disturbance in oxygenation and requires immediate intervention? (Select all that
apply)
A. SpO2 value of 95%
B. Retractions
C. Respiratory rate of 28 bpm
D. Nasal flaring
E. Clubbing of fingers
Answer: B, C, & D
Rationale: Retractions, tachypnea (RR >20), and nasal flaring are acute signs of
respiratory distress requiring immediate intervention. Clubbing is a chronic finding.
SpO2 of 95% is within normal range .
Q4. What are the early and late signs of hypoxia?
A. Early: cyanosis; Late: restlessness
B. Early: restlessness and confusion; Late: cyanosis
C. Early: bradycardia; Late: tachypnea
D. Early: euphoria; Late: hypotension
Answer: B. Early: restlessness and confusion; Late: cyanosis
Rationale: Early signs of hypoxia include apprehension, restlessness, and confusion due
to cerebral hypoxia. Cyanosis is a late sign indicating severe hypoxemia .
Q5. A patient with a tracheostomy has thick tenacious secretions. To maintain the
airway, the most appropriate action for the nurse includes:
A. Tracheal suctioning
B. Oropharyngeal suctioning
C. Nasotracheal suctioning
D. Orotracheal suctioning
Answer: A. Tracheal suctioning
, Rationale: For a patient with a tracheostomy, tracheal suctioning is the appropriate
method to remove secretions directly from the artificial airway. Other methods are used
for patients without artificial airways .
Q6. The nurse is preparing to suction a patient's tracheostomy. What is the
maximum time for each suction pass?
A. 5 seconds
B. 10–15 seconds
C. 30 seconds
D. 1 minute
Answer: B. 10–15 seconds
Rationale: Prolonged suctioning causes hypoxia and can trigger vagal stimulation
leading to bradycardia. The maximum suction time is 10-15 seconds per pass .
Q7. Which skills can the nurse delegate to assistive personnel (AP)? (Select all that
apply)
A. Initiate oxygen therapy via nasal cannula
B. Perform nasotracheal suctioning of a patient
C. Educate the patient about the use of an incentive spirometer
D. Assist with care of an established tracheostomy tube
E. Reposition a patient with a chest tube
Answer: D & E
Rationale: AP can assist with established tracheostomy care and reposition patients
with chest tubes. Assessment, initiation of oxygen therapy, and patient education
require RN-level judgment .
Q8. What is the normal range for Oxygen Saturation (SpO2) in a healthy adult?
A. 85–90%
B. 95–100%
