NUR 185 Exam 1: NUR 185 Practice Exam 1: Latest Updated A+ Score Guide Solution

What is the target oxygen saturation (SpO2) goal for an adult patient receiving oxygen therapy? A. 85% and above B. 88% and above C. 90% and above D. 92% and above Correct Answer: D Rationale: According to the course materials, the target oxygen saturation goal is 92% and above. Hypoxia is defined as reduced oxygen levels in tissues and cells. Question 2 A nurse admits a patient with a respiratory rate of 38 breaths/min, chest muscle retraction, a pulse oximetry reading of 87% on room air, and pink frothy sputum. Which intervention should the nurse implement first? A. Administer IV furosemide B. Apply Oxygen at 2 L/min C. Obtain an arterial blood gas (ABG) sample D. Place the patient flat in bed Correct Answer: B Rationale: The patient is demonstrating severe respiratory distress and hypoxia (SpO2 87%). The primary priority nursing action is to immediately apply oxygen therapy.Question 3 Which nursing action is essential to decrease the incidence of VentilatorAssociated Pneumonia (VAP) in an intubated patient? A. Keep the head of the bed flat B. Elevate the head of the bed to 30 to 45 degrees C. Change ventilator settings every shift D. Instill normal saline into the endotracheal tube before suctioning Correct Answer: B Rationale: Preventing VAP requires elevating the head of the bed to 30 to 45 degrees, performing regular oral care with chlorhexidine, cleaning equipment, and providing peptic ulcer prophylaxis. Question 4 If a ventilator alarm goes off continuously and the nurse cannot determine the cause after checking all tubing for disconnections and suctioning the patient, what is the immediate priority action? A. Turn off the ventilator alarm B. Call the respiratory therapist and wait at the bedside C. Disconnect the patient from the ventilator and manually ventilate with an Ambu bag D. Increase the oxygen concentration on the ventilator console Correct Answer: C Rationale: If ventilator alarms sound and the cause cannot be immediately resolved by checking tubing connections or suctioning, the nurse must disconnect the patient and manually ventilate using a manual resuscitation bag (Ambu bag). Question 5What is the correct protocol when performing endotracheal or tracheostomy suctioning? A. Instill 5 mL of normal saline prior to suctioning B. Suction continuously for at least 20 seconds per pass C. Hyper oxygenate before suctioning and limit each pass to a maximum of 10 seconds using sterile technique D. Maintain the patient in a flat supine position during the procedure Correct Answer: C Rationale: Suctioning requires sterile technique, preoxygenation/hyperoxygenation to prevent hypoxia, maintaining semi-Fowler positioning, applying suction only upon withdrawal, and limiting suction duration to no more than 10 seconds. Saline instillation is explicitly contraindicated. Question 6 What is the main physiological purpose of hyperoxygenating a patient prior to tracheostomy suctioning?