NR 224: Fundamentals of Nursing - Oxygenation and Documentation
2026 |Chamberlain
1. A nurse is assessing a patient for early signs of hypoxia. Which of the
following findings should the nurse expect?
A. Restlessness and anxiety
B. Cyanosis of the mucous membranes
C. Bradycardia
D. Bradypnea
Answer: A
Rationale: Restlessness, anxiety, and agitation are early clinical manifestations of hypoxia.
Cyanosis and bradycardia are late signs.
2. When documenting in a patient’s electronic health record, which action by
the nurse ensures legal accountability?
A. Sharing the password with a colleague during a busy shift
B. Leaving the computer terminal logged in while performing a quick task
C. Erasing an incorrect entry so it is no longer visible
D. Signing each entry electronically according to facility policy
Answer: D
Rationale: Proper electronic signature provides legal accountability. Sharing passwords,
leaving terminals logged in, and erasing entries are violations of security and legal
standards.
,3. A patient requires a precise concentration of oxygen at 35% FiO2. Which
oxygen delivery device is most appropriate?
A. Nasal Cannula
B. Simple Face Mask
C. Venturi Mask
D. Non-rebreather Mask
Answer: C
Rationale: The Venturi mask is the most accurate device for delivering a specific, fixed
concentration of oxygen (FiO2).
4. A nurse is using the SBAR technique to communicate with a physician. What
does the ‘A’ represent in SBAR?
A. Assessment
B. Action
C. Analysis
D. Accountability
Answer: A
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation.
5. What is the primary purpose of the medical record?
A. To provide a source of revenue for the hospital
B. To act as a personal diary for nursing staff
C. To serve as a tool for patient entertainment
D. To facilitate communication among health care providers
Answer: D
Rationale: The primary purpose of the medical record is to facilitate communication
among the interprofessional team to ensure continuity and quality of care.
, 6. A nurse discovers that a patient was given the wrong medication. What is the
first priority regarding documentation?
A. Document the facts of the occurrence in the patient’s record
B. Omit the error from the medical record to avoid legal issues
C. Note in the medical record that an incident report was filed
D. Wait 24 hours to see if any side effects occur before charting
Answer: A
Rationale: The nurse must document factual information about the medication
administered and the patient’s response. However, the nurse should never document in the
medical record that an incident report was filed.
7. Which clinical finding is considered a late sign of hypoxia?
A. Tachycardia
B. Elevated blood pressure
C. Apprehension
D. Cyanosis
Answer: D
Rationale: Cyanosis is a late sign of hypoxia, indicating severe oxygen deprivation. Early
signs include tachycardia and restlessness.
8. A nurse is teaching a patient how to use an incentive spirometer. What
instruction should the nurse provide?
A. Exhale forcefully into the device
B. Use the device only if you feel short of breath
C. Inhale slowly and deeply through the mouthpiece
D. Perform the exercise once every 4 hours
Answer: C
Rationale: Incentive spirometry requires slow, deep inhalations to expand the alveoli and
prevent atelectasis.
2026 |Chamberlain
1. A nurse is assessing a patient for early signs of hypoxia. Which of the
following findings should the nurse expect?
A. Restlessness and anxiety
B. Cyanosis of the mucous membranes
C. Bradycardia
D. Bradypnea
Answer: A
Rationale: Restlessness, anxiety, and agitation are early clinical manifestations of hypoxia.
Cyanosis and bradycardia are late signs.
2. When documenting in a patient’s electronic health record, which action by
the nurse ensures legal accountability?
A. Sharing the password with a colleague during a busy shift
B. Leaving the computer terminal logged in while performing a quick task
C. Erasing an incorrect entry so it is no longer visible
D. Signing each entry electronically according to facility policy
Answer: D
Rationale: Proper electronic signature provides legal accountability. Sharing passwords,
leaving terminals logged in, and erasing entries are violations of security and legal
standards.
,3. A patient requires a precise concentration of oxygen at 35% FiO2. Which
oxygen delivery device is most appropriate?
A. Nasal Cannula
B. Simple Face Mask
C. Venturi Mask
D. Non-rebreather Mask
Answer: C
Rationale: The Venturi mask is the most accurate device for delivering a specific, fixed
concentration of oxygen (FiO2).
4. A nurse is using the SBAR technique to communicate with a physician. What
does the ‘A’ represent in SBAR?
A. Assessment
B. Action
C. Analysis
D. Accountability
Answer: A
Rationale: SBAR stands for Situation, Background, Assessment, and Recommendation.
5. What is the primary purpose of the medical record?
A. To provide a source of revenue for the hospital
B. To act as a personal diary for nursing staff
C. To serve as a tool for patient entertainment
D. To facilitate communication among health care providers
Answer: D
Rationale: The primary purpose of the medical record is to facilitate communication
among the interprofessional team to ensure continuity and quality of care.
, 6. A nurse discovers that a patient was given the wrong medication. What is the
first priority regarding documentation?
A. Document the facts of the occurrence in the patient’s record
B. Omit the error from the medical record to avoid legal issues
C. Note in the medical record that an incident report was filed
D. Wait 24 hours to see if any side effects occur before charting
Answer: A
Rationale: The nurse must document factual information about the medication
administered and the patient’s response. However, the nurse should never document in the
medical record that an incident report was filed.
7. Which clinical finding is considered a late sign of hypoxia?
A. Tachycardia
B. Elevated blood pressure
C. Apprehension
D. Cyanosis
Answer: D
Rationale: Cyanosis is a late sign of hypoxia, indicating severe oxygen deprivation. Early
signs include tachycardia and restlessness.
8. A nurse is teaching a patient how to use an incentive spirometer. What
instruction should the nurse provide?
A. Exhale forcefully into the device
B. Use the device only if you feel short of breath
C. Inhale slowly and deeply through the mouthpiece
D. Perform the exercise once every 4 hours
Answer: C
Rationale: Incentive spirometry requires slow, deep inhalations to expand the alveoli and
prevent atelectasis.
