,NR 224 Exam 3 Fundamentals - Skills | Practice Questions & Answers
2026/2027 | Chamberlain
1.** A nurse is assessing a client who has a suspected diagnosis of hypoxia.
Which of the following is a **late** clinical manifestation of hypoxia?
A) Restlessness
B) Tachycardia
C) Cyanosis
D) Elevated blood pressure
**Correct Answer:** C) Cyanosis
**Rationale:** Cyanosis is a late sign of hypoxia; early signs include
restlessness, tachycardia, tachypnea, and elevated blood pressure. Late
signs also include bradycardia, confusion, and hypotension.
---
**2.** When performing oropharyngeal suctioning for a client, which action
should the nurse take?
A) Apply suction while inserting the catheter
B) Suction for 30 seconds at a time
C) Apply suction only while withdrawing the catheter
D) Use clean gloves for the entire procedure
**Correct Answer:** C) Apply suction only while withdrawing the catheter
,**Rationale:** Suction should only be applied while withdrawing the catheter
to prevent tissue damage and hypoxia. Suctioning should be limited to 10-15
seconds per pass.
---
**3.** A nurse is caring for a client with a nasal cannula. Which of the
following is the maximum recommended flow rate for this device?
A) 2 L/min
B) 4 L/min
C) 6 L/min
D) 10 L/min
**Correct Answer:** C) 6 L/min
**Rationale:** A nasal cannula is typically used for flow rates of 1 to 6 L/min;
higher rates can dry out the mucosa and cause discomfort.
---
**4.** A client is using an incentive spirometer. Which instruction should the
nurse provide?
A) Inhale slowly and deeply through the mouthpiece
B) Exhale forcefully into the device
C) Use the device once every 4 hours
D) Hold your breath for 30 seconds after inhalation
, **Correct Answer:** A) Inhale slowly and deeply through the mouthpiece
**Rationale:** Incentive spirometry requires the client to inhale slowly to
expand the lungs and prevent atelectasis. The device should be used 10-12
times per hour while awake.
---
**5.** A nurse is interpreting ABG results: pH 7.30, PaCO₂ 52 mmHg, and
HCO₃ 26 mEq/L. What is the interpretation?
A) Metabolic Acidosis
B) Respiratory Alkalosis
C) Metabolic Alkalosis
D) Respiratory Acidosis
**Correct Answer:** D) Respiratory Acidosis
**Rationale:** A low pH (<7.35) combined with a high PaCO₂ (>45 mmHg)
indicates respiratory acidosis. The elevated HCO₃ suggests metabolic
compensation.
---
**6.** Which oxygen delivery device provides the most precise concentration
of oxygen?
A) Simple face mask
2026/2027 | Chamberlain
1.** A nurse is assessing a client who has a suspected diagnosis of hypoxia.
Which of the following is a **late** clinical manifestation of hypoxia?
A) Restlessness
B) Tachycardia
C) Cyanosis
D) Elevated blood pressure
**Correct Answer:** C) Cyanosis
**Rationale:** Cyanosis is a late sign of hypoxia; early signs include
restlessness, tachycardia, tachypnea, and elevated blood pressure. Late
signs also include bradycardia, confusion, and hypotension.
---
**2.** When performing oropharyngeal suctioning for a client, which action
should the nurse take?
A) Apply suction while inserting the catheter
B) Suction for 30 seconds at a time
C) Apply suction only while withdrawing the catheter
D) Use clean gloves for the entire procedure
**Correct Answer:** C) Apply suction only while withdrawing the catheter
,**Rationale:** Suction should only be applied while withdrawing the catheter
to prevent tissue damage and hypoxia. Suctioning should be limited to 10-15
seconds per pass.
---
**3.** A nurse is caring for a client with a nasal cannula. Which of the
following is the maximum recommended flow rate for this device?
A) 2 L/min
B) 4 L/min
C) 6 L/min
D) 10 L/min
**Correct Answer:** C) 6 L/min
**Rationale:** A nasal cannula is typically used for flow rates of 1 to 6 L/min;
higher rates can dry out the mucosa and cause discomfort.
---
**4.** A client is using an incentive spirometer. Which instruction should the
nurse provide?
A) Inhale slowly and deeply through the mouthpiece
B) Exhale forcefully into the device
C) Use the device once every 4 hours
D) Hold your breath for 30 seconds after inhalation
, **Correct Answer:** A) Inhale slowly and deeply through the mouthpiece
**Rationale:** Incentive spirometry requires the client to inhale slowly to
expand the lungs and prevent atelectasis. The device should be used 10-12
times per hour while awake.
---
**5.** A nurse is interpreting ABG results: pH 7.30, PaCO₂ 52 mmHg, and
HCO₃ 26 mEq/L. What is the interpretation?
A) Metabolic Acidosis
B) Respiratory Alkalosis
C) Metabolic Alkalosis
D) Respiratory Acidosis
**Correct Answer:** D) Respiratory Acidosis
**Rationale:** A low pH (<7.35) combined with a high PaCO₂ (>45 mmHg)
indicates respiratory acidosis. The elevated HCO₃ suggests metabolic
compensation.
---
**6.** Which oxygen delivery device provides the most precise concentration
of oxygen?
A) Simple face mask
