NSG 300/NSG300 Exam 4 V1 | Foundations
of Nursing Q&A with Rationale | Grand
Canyon University
1. A nurse is suctioning a patient with a tracheostomy. Which action is the priority for the
nurse to prevent hypoxia during the procedure?
A. Suctioning for 30 seconds at a time.
B. Pre-oxygenating the patient with 100% oxygen.
C. Applying suction while inserting the catheter.
D. Using clean technique during the procedure.
Correct Answer: B
Expert Explanation: Pre-oxygenation with 100% oxygen is essential because suctioning
removes both secretions and oxygen from the airway. The nurse should limit suctioning to
10 to 15 seconds per pass to minimize the risk of hypoxia and cardiac arrhythmias. Sterile
technique is required for tracheostomy suctioning to prevent healthcare-associated
infections.
2. When assessing a patient who is 6 hours post-operative, the nurse notes that the patient
has not voided. What is the nurse’s first action?
A. Increase the IV fluid rate.
B. Insert a straight catheter immediately.
,C. Perform a bladder scan.
D. Notify the surgeon of possible renal failure.
Correct Answer: C
Expert Explanation: A bladder scan is a non-invasive way to assess the volume of urine in
the bladder and determine if the patient is experiencing urinary retention. Post-operative
urinary retention is common due to anesthesia and narcotics. Assessing the bladder
volume provides the data needed to decide if catheterization is necessary.
3. A patient is receiving oxygen via a simple face mask at 8 L/min. The nurse knows that the
minimum flow rate for this device is typically 5-6 L/min to prevent which of the following?
A. Rebreathing of carbon dioxide.
B. Nasal mucosal drying.
C. Oxygen toxicity.
D. Skin breakdown on the ears.
Correct Answer: A
Expert Explanation: The flow rate for a simple face mask must be at least 5 to 6 L/min to
flush out exhaled carbon dioxide from the mask. If the flow rate is too low, the patient may
rebreathe CO2, leading to respiratory distress or acidosis. The nurse should always ensure
the flow meter is set correctly for the specific device in use.
, 4. Which of the following is a symptom of Malignant Hyperthermia that the nurse should
monitor for during the intraoperative period?
A. Bradycardia and hypotension.
B. Muscle rigidity and increased end-tidal CO2.
C. Hyperthermia as the very first sign.
D. Decreased respiratory rate.
Correct Answer: B
Expert Explanation: Malignant Hyperthermia is a life-threatening complication of general
anesthesia characterized by rapid onset of muscle rigidity and hypermetabolism. Increased
end-tidal CO2 is often the earliest sign of the metabolic crisis occurring. While high fever
eventually occurs, it is usually a late sign, making early recognition of muscle stiffness and
tachycardia critical.
5. A nurse is teaching a patient about using an incentive spirometer. Which instruction should
the nurse include?
A. Inhale slowly and deeply to raise the piston.
B. Exhale forcefully into the device.
C. Use the device once every 4 hours while awake.
D. Hold your breath for 30 seconds after inhalation.
Correct Answer: A
of Nursing Q&A with Rationale | Grand
Canyon University
1. A nurse is suctioning a patient with a tracheostomy. Which action is the priority for the
nurse to prevent hypoxia during the procedure?
A. Suctioning for 30 seconds at a time.
B. Pre-oxygenating the patient with 100% oxygen.
C. Applying suction while inserting the catheter.
D. Using clean technique during the procedure.
Correct Answer: B
Expert Explanation: Pre-oxygenation with 100% oxygen is essential because suctioning
removes both secretions and oxygen from the airway. The nurse should limit suctioning to
10 to 15 seconds per pass to minimize the risk of hypoxia and cardiac arrhythmias. Sterile
technique is required for tracheostomy suctioning to prevent healthcare-associated
infections.
2. When assessing a patient who is 6 hours post-operative, the nurse notes that the patient
has not voided. What is the nurse’s first action?
A. Increase the IV fluid rate.
B. Insert a straight catheter immediately.
,C. Perform a bladder scan.
D. Notify the surgeon of possible renal failure.
Correct Answer: C
Expert Explanation: A bladder scan is a non-invasive way to assess the volume of urine in
the bladder and determine if the patient is experiencing urinary retention. Post-operative
urinary retention is common due to anesthesia and narcotics. Assessing the bladder
volume provides the data needed to decide if catheterization is necessary.
3. A patient is receiving oxygen via a simple face mask at 8 L/min. The nurse knows that the
minimum flow rate for this device is typically 5-6 L/min to prevent which of the following?
A. Rebreathing of carbon dioxide.
B. Nasal mucosal drying.
C. Oxygen toxicity.
D. Skin breakdown on the ears.
Correct Answer: A
Expert Explanation: The flow rate for a simple face mask must be at least 5 to 6 L/min to
flush out exhaled carbon dioxide from the mask. If the flow rate is too low, the patient may
rebreathe CO2, leading to respiratory distress or acidosis. The nurse should always ensure
the flow meter is set correctly for the specific device in use.
, 4. Which of the following is a symptom of Malignant Hyperthermia that the nurse should
monitor for during the intraoperative period?
A. Bradycardia and hypotension.
B. Muscle rigidity and increased end-tidal CO2.
C. Hyperthermia as the very first sign.
D. Decreased respiratory rate.
Correct Answer: B
Expert Explanation: Malignant Hyperthermia is a life-threatening complication of general
anesthesia characterized by rapid onset of muscle rigidity and hypermetabolism. Increased
end-tidal CO2 is often the earliest sign of the metabolic crisis occurring. While high fever
eventually occurs, it is usually a late sign, making early recognition of muscle stiffness and
tachycardia critical.
5. A nurse is teaching a patient about using an incentive spirometer. Which instruction should
the nurse include?
A. Inhale slowly and deeply to raise the piston.
B. Exhale forcefully into the device.
C. Use the device once every 4 hours while awake.
D. Hold your breath for 30 seconds after inhalation.
Correct Answer: A
