,NSG 3130 Exam 4 | Fundamental Concepts & Skills II
(2026/2027) PDF | Nursing | Galen
1. A client with a new tracheostomy requires tracheostomy tie replacement.
Which action is most important to prevent accidental decannulation?
A) Have a second nurse hold the tracheostomy tube securely during the tie
change.
B) Ask the client to hold the tube while the ties are replaced.
C) Remove the inner cannula before changing the ties.
D) Position the client flat and instruct them not to move.
Correct Answer: A) Have a second nurse hold the tracheostomy tube securely
during the tie change.
Rationale: Accidental decannulation is a life-threatening emergency. A second
nurse stabilizes the tracheostomy tube while the ties are changed, preventing
dislodgement if the client coughs or moves. The client cannot reliably hold the
tube. Removing the inner cannula or positioning flat does not secure the airway.
2. The nurse is preparing to suction an adult client's nasopharyngeal airway.
Which intervention best prevents hypoxia during the procedure?
A) Limit suctioning to 30 seconds per pass.
B) Hyperoxygenate the client with 100% oxygen before and after suctioning.
C) Apply a water-soluble lubricant to the catheter.
D) Use clean technique instead of sterile technique.
,Correct Answer: B) Hyperoxygenate the client with 100% oxygen before and
after suctioning.
Rationale: Hyperoxygenation before and after suctioning prevents hypoxia, a
common complication of airway suctioning. Suctioning should be limited to 10
to 15 seconds per pass. Lubricant eases insertion but does not prevent hypoxia.
Sterile technique is required to reduce infection risk.
3. A client with a chest tube develops new subcutaneous emphysema around
the insertion site. What is the priority nursing action?
A) Clamp the chest tube near the insertion site.
B) Administer the prescribed analgesic.
C) Notify the healthcare provider immediately.
D) Reposition the client onto the unaffected side.
Correct Answer: C) Notify the healthcare provider immediately.
Rationale: Subcutaneous emphysema indicates air leaking into tissues and may
signal chest tube malfunction or a new air leak. The provider must be notified
immediately for evaluation. Clamping can cause tension pneumothorax and is
contraindicated. Analgesics and repositioning do not address the underlying
problem.
4. The nurse reviews arterial blood gas results: pH 7.28, PaCO2 55 mm Hg, HCO3
24 mEq/L. How should the nurse interpret these results?
A) Metabolic acidosis
B) Respiratory alkalosis
, C) Fully compensated respiratory acidosis
D) Uncompensated respiratory acidosis
Correct Answer: D) Uncompensated respiratory acidosis
Rationale: The low pH indicates acidosis, and the elevated PaCO2 indicates a
respiratory cause. The normal HCO3 shows no metabolic compensation has
occurred, so this is uncompensated respiratory acidosis. Metabolic acidosis
would have low HCO3, and respiratory alkalosis would have high pH and low
PaCO2.
5. A client scheduled for surgery reports chest pain during the preoperative
assessment. Which action should the nurse take?
A) Notify the surgeon immediately.
B) Document the finding and continue preparation.
C) Administer an antacid and reassess in 30 minutes.
D) Tell the client that anxiety is causing the pain.
Correct Answer: A) Notify the surgeon immediately.
Rationale: Chest pain preoperatively may indicate cardiac ischemia or another
serious condition and requires immediate surgeon notification. Documenting
without action delays treatment. Antacids are inappropriate without a
diagnosis. Dismissing pain as anxiety is unsafe.
6. The nurse is preparing a client for surgery. Which intervention most
effectively prevents surgical site infection?
(2026/2027) PDF | Nursing | Galen
1. A client with a new tracheostomy requires tracheostomy tie replacement.
Which action is most important to prevent accidental decannulation?
A) Have a second nurse hold the tracheostomy tube securely during the tie
change.
B) Ask the client to hold the tube while the ties are replaced.
C) Remove the inner cannula before changing the ties.
D) Position the client flat and instruct them not to move.
Correct Answer: A) Have a second nurse hold the tracheostomy tube securely
during the tie change.
Rationale: Accidental decannulation is a life-threatening emergency. A second
nurse stabilizes the tracheostomy tube while the ties are changed, preventing
dislodgement if the client coughs or moves. The client cannot reliably hold the
tube. Removing the inner cannula or positioning flat does not secure the airway.
2. The nurse is preparing to suction an adult client's nasopharyngeal airway.
Which intervention best prevents hypoxia during the procedure?
A) Limit suctioning to 30 seconds per pass.
B) Hyperoxygenate the client with 100% oxygen before and after suctioning.
C) Apply a water-soluble lubricant to the catheter.
D) Use clean technique instead of sterile technique.
,Correct Answer: B) Hyperoxygenate the client with 100% oxygen before and
after suctioning.
Rationale: Hyperoxygenation before and after suctioning prevents hypoxia, a
common complication of airway suctioning. Suctioning should be limited to 10
to 15 seconds per pass. Lubricant eases insertion but does not prevent hypoxia.
Sterile technique is required to reduce infection risk.
3. A client with a chest tube develops new subcutaneous emphysema around
the insertion site. What is the priority nursing action?
A) Clamp the chest tube near the insertion site.
B) Administer the prescribed analgesic.
C) Notify the healthcare provider immediately.
D) Reposition the client onto the unaffected side.
Correct Answer: C) Notify the healthcare provider immediately.
Rationale: Subcutaneous emphysema indicates air leaking into tissues and may
signal chest tube malfunction or a new air leak. The provider must be notified
immediately for evaluation. Clamping can cause tension pneumothorax and is
contraindicated. Analgesics and repositioning do not address the underlying
problem.
4. The nurse reviews arterial blood gas results: pH 7.28, PaCO2 55 mm Hg, HCO3
24 mEq/L. How should the nurse interpret these results?
A) Metabolic acidosis
B) Respiratory alkalosis
, C) Fully compensated respiratory acidosis
D) Uncompensated respiratory acidosis
Correct Answer: D) Uncompensated respiratory acidosis
Rationale: The low pH indicates acidosis, and the elevated PaCO2 indicates a
respiratory cause. The normal HCO3 shows no metabolic compensation has
occurred, so this is uncompensated respiratory acidosis. Metabolic acidosis
would have low HCO3, and respiratory alkalosis would have high pH and low
PaCO2.
5. A client scheduled for surgery reports chest pain during the preoperative
assessment. Which action should the nurse take?
A) Notify the surgeon immediately.
B) Document the finding and continue preparation.
C) Administer an antacid and reassess in 30 minutes.
D) Tell the client that anxiety is causing the pain.
Correct Answer: A) Notify the surgeon immediately.
Rationale: Chest pain preoperatively may indicate cardiac ischemia or another
serious condition and requires immediate surgeon notification. Documenting
without action delays treatment. Antacids are inappropriate without a
diagnosis. Dismissing pain as anxiety is unsafe.
6. The nurse is preparing a client for surgery. Which intervention most
effectively prevents surgical site infection?
