,NR 224 Fundamentals Skills Exam 3 | Chamberlain
1. A nurse is preparing to enter the room of a client on contact precautions for Clostridioides difficile.
Which action should the nurse take first?
A) Apply a clean gown and gloves
B) Perform hand hygiene with alcohol-based rub
C) Perform hand hygiene with soap and water
D) Don an N95 respirator
Correct Answer: Perform hand hygiene with soap and water
Rationale: Contact precautions for C. difficile require hand hygiene with soap and water before
donning PPE because alcohol-based rubs do not kill C. difficile spores. After hand hygiene, the nurse
should don a gown and gloves. An N95 respirator is not required for contact precautions.
2. A nurse is assessing a client who has a suspected diagnosis of hypoxia. Which finding is a late
clinical manifestation of hypoxia?
A) Restlessness
B) Tachycardia
C) Cyanosis
D) Elevated blood pressure
Correct Answer: Cyanosis
Rationale: Cyanosis is a late sign of hypoxia, indicating severe oxygen deprivation. Early signs include
restlessness, tachycardia, tachypnea, and elevated blood pressure. Late signs also include bradycardia,
confusion, and hypotension. Prompt recognition of early signs allows for timely intervention.
3. 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: Apply suction only while withdrawing the catheter
Rationale: Suction should only be applied while withdrawing the catheter to prevent tissue damage
and hypoxia. Suctioning during insertion can cause mucosal injury. Each suction pass should be limited
to 10-15 seconds. Sterile gloves are required for oropharyngeal suctioning.
4. A nurse is caring for a client with a nasal cannula. Which flow rate is the maximum recommended
for this device?
A) 2 L/min
B) 6 L/min
C) 4 L/min
D) 10 L/min
Correct Answer: 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
nasal mucosa and do not significantly increase oxygenation. The FiO2 delivered ranges from 24% to
44% depending on the flow rate.
5. 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: Inhale slowly and deeply through the mouthpiece
, Rationale: Incentive spirometry requires the client to inhale slowly and deeply to expand the lungs
and prevent atelectasis. The client should hold the breath for 3-5 seconds after inhalation. The device
should be used 10-12 times per hour while awake, not once every 4 hours.
6. A nurse is interpreting ABG results: pH 7.30, PaCO2 52 mmHg, and HCO3 26 mEq/L. Which acid-base
imbalance should the nurse identify?
A) Metabolic Acidosis
B) Respiratory Alkalosis
C) Metabolic Alkalosis
D) Respiratory Acidosis
Correct Answer: Respiratory Acidosis
Rationale: A low pH (< 7.35) combined with a high PaCO2 (> 45 mmHg) indicates respiratory acidosis.
The HCO3 of 26 mEq/L is within normal limits, indicating no metabolic compensation. This condition is
caused by hypoventilation and requires interventions to improve ventilation.
7. Which oxygen delivery device provides the most precise concentration of oxygen?
A) Simple face mask
B) Non-rebreather mask
C) Venturi mask
D) Nasal cannula
Correct Answer: Venturi mask
Rationale: The Venturi mask uses different sized adapters to deliver a specific and precise FiO2,
making it the most accurate device for oxygen delivery. The simple face mask and non-rebreather
mask deliver approximate concentrations, and the nasal cannula delivers variable FiO2 depending on
the client's respiratory pattern.
8. A nurse is assessing a client for fluid volume deficit. Which finding should the nurse expect?
A) Distended neck veins
1. A nurse is preparing to enter the room of a client on contact precautions for Clostridioides difficile.
Which action should the nurse take first?
A) Apply a clean gown and gloves
B) Perform hand hygiene with alcohol-based rub
C) Perform hand hygiene with soap and water
D) Don an N95 respirator
Correct Answer: Perform hand hygiene with soap and water
Rationale: Contact precautions for C. difficile require hand hygiene with soap and water before
donning PPE because alcohol-based rubs do not kill C. difficile spores. After hand hygiene, the nurse
should don a gown and gloves. An N95 respirator is not required for contact precautions.
2. A nurse is assessing a client who has a suspected diagnosis of hypoxia. Which finding is a late
clinical manifestation of hypoxia?
A) Restlessness
B) Tachycardia
C) Cyanosis
D) Elevated blood pressure
Correct Answer: Cyanosis
Rationale: Cyanosis is a late sign of hypoxia, indicating severe oxygen deprivation. Early signs include
restlessness, tachycardia, tachypnea, and elevated blood pressure. Late signs also include bradycardia,
confusion, and hypotension. Prompt recognition of early signs allows for timely intervention.
3. 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: Apply suction only while withdrawing the catheter
Rationale: Suction should only be applied while withdrawing the catheter to prevent tissue damage
and hypoxia. Suctioning during insertion can cause mucosal injury. Each suction pass should be limited
to 10-15 seconds. Sterile gloves are required for oropharyngeal suctioning.
4. A nurse is caring for a client with a nasal cannula. Which flow rate is the maximum recommended
for this device?
A) 2 L/min
B) 6 L/min
C) 4 L/min
D) 10 L/min
Correct Answer: 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
nasal mucosa and do not significantly increase oxygenation. The FiO2 delivered ranges from 24% to
44% depending on the flow rate.
5. 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: Inhale slowly and deeply through the mouthpiece
, Rationale: Incentive spirometry requires the client to inhale slowly and deeply to expand the lungs
and prevent atelectasis. The client should hold the breath for 3-5 seconds after inhalation. The device
should be used 10-12 times per hour while awake, not once every 4 hours.
6. A nurse is interpreting ABG results: pH 7.30, PaCO2 52 mmHg, and HCO3 26 mEq/L. Which acid-base
imbalance should the nurse identify?
A) Metabolic Acidosis
B) Respiratory Alkalosis
C) Metabolic Alkalosis
D) Respiratory Acidosis
Correct Answer: Respiratory Acidosis
Rationale: A low pH (< 7.35) combined with a high PaCO2 (> 45 mmHg) indicates respiratory acidosis.
The HCO3 of 26 mEq/L is within normal limits, indicating no metabolic compensation. This condition is
caused by hypoventilation and requires interventions to improve ventilation.
7. Which oxygen delivery device provides the most precise concentration of oxygen?
A) Simple face mask
B) Non-rebreather mask
C) Venturi mask
D) Nasal cannula
Correct Answer: Venturi mask
Rationale: The Venturi mask uses different sized adapters to deliver a specific and precise FiO2,
making it the most accurate device for oxygen delivery. The simple face mask and non-rebreather
mask deliver approximate concentrations, and the nasal cannula delivers variable FiO2 depending on
the client's respiratory pattern.
8. A nurse is assessing a client for fluid volume deficit. Which finding should the nurse expect?
A) Distended neck veins
