NSG 3130 Exam 4 NSG 3130 Fundamental
Concepts & Skills II Questions and verified
Answers with Rationale
1
A nurse finds a patient in cardiopulmonary arrest with no pulse or spontaneous
respirations. Which oxygen delivery device must the nurse use?
A. Non-rebreather mask
B. Bag-valve-mask (BVM) unit
C. Continuous positive airway pressure (CPAP)
D. High-flow nasal cannula
Answer: B
,Rationale: A bag-valve-mask (BVM) unit is required to manually ventilate a patient
who is not breathing on their own. Non-rebreather masks and nasal cannulas require
spontaneous respirations to function.
Question 2
A patient with severe chronic obstructive pulmonary disease (COPD) is becoming
increasingly confused and disoriented. What is the priority nursing action?
A. Administer a mild sedative.
B. Increase oxygen flow until pulse oximetry exceeds 98%.
C. Obtain an arterial blood gas (ABG) sample.
D. Lower the head of the bed.
Answer: C
Rationale: Increasing confusion in a COPD patient often signifies hypercapnia
(carbon dioxide retention). An arterial blood gas (ABG) sample must be drawn to
verify CO2 levels before increasing oxygen, which could potentially depress their
hypoxic respiratory drive.
Question 3
Which oxygen delivery device provides the most precise and controlled
concentration of oxygen?
A. Simple face mask
B. Venturi mask
C. Nasal cannula
D. Partial rebreather mask
Answer: B
Rationale: The Venturi mask uses specific color-coded adapters or dial settings to
deliver a highly accurate and precise percentage of oxygen, making it the ideal
choice for patients with chronic lung conditions.
Question 4
While performing tracheostomy care, how long should the nurse apply intermittent
suctioning during a single pass?
A. 5 to 10 seconds
B. 10 to 15 seconds
C. 20 to 25 seconds
D. As long as it takes to clear the airway
Answer: B
Rationale: Suction should be applied intermittently for no more than 10 to 15
seconds at a time to prevent profound hypoxia and mucosal damage.
Question 5
Which task regarding tracheostomy care can the registered nurse safely delegate to
an unlicensed assistive personnel (UAP)?
,A. Suctioning a new tracheostomy airway
B. Performing a sterile tracheostomy dressing change
C. Cleaning and replacing an inner cannula
D. Providing routine oral care around the site
Answer: D
Rationale: Stable, non-sterile hygiene tasks such as basic oral care can be
delegated to a UAP. Suctioning and inner cannula care involve clinical judgment and
sterile techniques that must be performed by a licensed nurse.
Question 6
A postoperative patient is at risk for developing atelectasis. What preventative
intervention should the nurse emphasize?
A. Restricting fluid intake to decrease secretions
B. Using the incentive spirometer 10 times every hour while awake
C. Maintaining a supine position for lung expansion
D. Administering prophylactic antitussives
Answer: B
Rationale: Frequent use of an incentive spirometer promotes deep breathing,
expands alveolar spaces, and directly prevents atelectasis following surgical
procedures.
Question 7
The nurse notes alternating periods of deep breathing and apnea on a patient's
monitor. What respiratory pattern is this?
A. Kussmaul respirations
B. Biot's respirations
C. Cheyne-Stokes respirations
D. Bradypnea
Answer: C
Rationale: Cheyne-Stokes respirations feature a gradual increase in depth
followed by a gradual decrease, ending in a period of apnea. This pattern is common
in severe heart failure or end-of-life care.
Question 8
When preparing to apply a simple face mask with oxygen and humidification, what
should the nurse do first?
A. Secure the mask tightly over the face.
B. Verify the oxygen flow rate is set to at least 5 L/min.
C. Apply water-soluble jelly to the patient's nose.
D. Set the flow rate to 2 L/min.
Answer: B
, Rationale: A simple face mask must always be set to a minimum of 5 to 6 L/min to
flush out accumulated carbon dioxide from inside the mask, preventing the patient
from rebreathing expired air.
Part 2: Circulation and Cardiovascular Health
Question 9
A patient presents with crackles in the lungs, orthopnea, and severe dyspnea. The
nurse recognizes these as hallmark clinical manifestations of:
A. Right-sided heart failure
B. Left-sided heart failure
C. Deep vein thrombosis
D. Peripheral artery disease
Answer: B
Rationale: Left-sided heart failure causes blood to back up into the pulmonary
vasculature, resulting in respiratory symptoms such as pulmonary congestion,
crackles, shortness of breath, and difficulty breathing while lying flat (orthopnea).
Question 10
The nurse is reviewing lipid panel results for a patient evaluating cardiovascular
health. Which finding requires immediate nursing education?
A. Total cholesterol of 180 mg/dL
B. Low-density lipoprotein (LDL) of 165 mg/dL
C. High-density lipoprotein (HDL) of 55 mg/dL
D. Triglycerides of 140 mg/dL
Answer: B
Rationale: Standard cardiovascular targets state that LDL levels should be less
than 130 mg/dL (and ideally under 100 mg/dL). An LDL of 165 mg/dL is elevated
and increases the risk for atherosclerosis.
Question 11
A patient diagnosed with atrial fibrillation is prescribed warfarin (Coumadin) therapy.
What is the primary clinical goal of this treatment?
A. Dissolving existing blood clots in the lower extremities
B. Lowering systemic arterial blood pressure
C. Preventing stroke by slowing clot formation in the atria
D. Stabilizing the cardiac rhythm back to normal sinus
Concepts & Skills II Questions and verified
Answers with Rationale
1
A nurse finds a patient in cardiopulmonary arrest with no pulse or spontaneous
respirations. Which oxygen delivery device must the nurse use?
A. Non-rebreather mask
B. Bag-valve-mask (BVM) unit
C. Continuous positive airway pressure (CPAP)
D. High-flow nasal cannula
Answer: B
,Rationale: A bag-valve-mask (BVM) unit is required to manually ventilate a patient
who is not breathing on their own. Non-rebreather masks and nasal cannulas require
spontaneous respirations to function.
Question 2
A patient with severe chronic obstructive pulmonary disease (COPD) is becoming
increasingly confused and disoriented. What is the priority nursing action?
A. Administer a mild sedative.
B. Increase oxygen flow until pulse oximetry exceeds 98%.
C. Obtain an arterial blood gas (ABG) sample.
D. Lower the head of the bed.
Answer: C
Rationale: Increasing confusion in a COPD patient often signifies hypercapnia
(carbon dioxide retention). An arterial blood gas (ABG) sample must be drawn to
verify CO2 levels before increasing oxygen, which could potentially depress their
hypoxic respiratory drive.
Question 3
Which oxygen delivery device provides the most precise and controlled
concentration of oxygen?
A. Simple face mask
B. Venturi mask
C. Nasal cannula
D. Partial rebreather mask
Answer: B
Rationale: The Venturi mask uses specific color-coded adapters or dial settings to
deliver a highly accurate and precise percentage of oxygen, making it the ideal
choice for patients with chronic lung conditions.
Question 4
While performing tracheostomy care, how long should the nurse apply intermittent
suctioning during a single pass?
A. 5 to 10 seconds
B. 10 to 15 seconds
C. 20 to 25 seconds
D. As long as it takes to clear the airway
Answer: B
Rationale: Suction should be applied intermittently for no more than 10 to 15
seconds at a time to prevent profound hypoxia and mucosal damage.
Question 5
Which task regarding tracheostomy care can the registered nurse safely delegate to
an unlicensed assistive personnel (UAP)?
,A. Suctioning a new tracheostomy airway
B. Performing a sterile tracheostomy dressing change
C. Cleaning and replacing an inner cannula
D. Providing routine oral care around the site
Answer: D
Rationale: Stable, non-sterile hygiene tasks such as basic oral care can be
delegated to a UAP. Suctioning and inner cannula care involve clinical judgment and
sterile techniques that must be performed by a licensed nurse.
Question 6
A postoperative patient is at risk for developing atelectasis. What preventative
intervention should the nurse emphasize?
A. Restricting fluid intake to decrease secretions
B. Using the incentive spirometer 10 times every hour while awake
C. Maintaining a supine position for lung expansion
D. Administering prophylactic antitussives
Answer: B
Rationale: Frequent use of an incentive spirometer promotes deep breathing,
expands alveolar spaces, and directly prevents atelectasis following surgical
procedures.
Question 7
The nurse notes alternating periods of deep breathing and apnea on a patient's
monitor. What respiratory pattern is this?
A. Kussmaul respirations
B. Biot's respirations
C. Cheyne-Stokes respirations
D. Bradypnea
Answer: C
Rationale: Cheyne-Stokes respirations feature a gradual increase in depth
followed by a gradual decrease, ending in a period of apnea. This pattern is common
in severe heart failure or end-of-life care.
Question 8
When preparing to apply a simple face mask with oxygen and humidification, what
should the nurse do first?
A. Secure the mask tightly over the face.
B. Verify the oxygen flow rate is set to at least 5 L/min.
C. Apply water-soluble jelly to the patient's nose.
D. Set the flow rate to 2 L/min.
Answer: B
, Rationale: A simple face mask must always be set to a minimum of 5 to 6 L/min to
flush out accumulated carbon dioxide from inside the mask, preventing the patient
from rebreathing expired air.
Part 2: Circulation and Cardiovascular Health
Question 9
A patient presents with crackles in the lungs, orthopnea, and severe dyspnea. The
nurse recognizes these as hallmark clinical manifestations of:
A. Right-sided heart failure
B. Left-sided heart failure
C. Deep vein thrombosis
D. Peripheral artery disease
Answer: B
Rationale: Left-sided heart failure causes blood to back up into the pulmonary
vasculature, resulting in respiratory symptoms such as pulmonary congestion,
crackles, shortness of breath, and difficulty breathing while lying flat (orthopnea).
Question 10
The nurse is reviewing lipid panel results for a patient evaluating cardiovascular
health. Which finding requires immediate nursing education?
A. Total cholesterol of 180 mg/dL
B. Low-density lipoprotein (LDL) of 165 mg/dL
C. High-density lipoprotein (HDL) of 55 mg/dL
D. Triglycerides of 140 mg/dL
Answer: B
Rationale: Standard cardiovascular targets state that LDL levels should be less
than 130 mg/dL (and ideally under 100 mg/dL). An LDL of 165 mg/dL is elevated
and increases the risk for atherosclerosis.
Question 11
A patient diagnosed with atrial fibrillation is prescribed warfarin (Coumadin) therapy.
What is the primary clinical goal of this treatment?
A. Dissolving existing blood clots in the lower extremities
B. Lowering systemic arterial blood pressure
C. Preventing stroke by slowing clot formation in the atria
D. Stabilizing the cardiac rhythm back to normal sinus
