NR 224 Fundamentals of Nursing Exam 7 Study Guide 2026
|Chamberlain College
1. Which assessment finding is the earliest sign of hypoxia in a client?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Decreased respiratory rate
Answer: B
Rationale: Restlessness and apprehension are the earliest signs of hypoxia. Cyanosis and
changes in heart rate or respiratory rate are often late signs.
2. When performing tracheostomy care, which action by the nurse is correct?
A. Removing the old ties before securing the new ones
B. Cutting a 4x4 gauze pad to place around the stoma
C. Suctioning the patient for 30 seconds at a time
D. Cleaning the inner cannula with hydrogen peroxide then rinsing with sterile saline
Answer: D
Rationale: The inner cannula is cleaned with half-strength peroxide and rinsed with saline.
Gauze should not be cut as fibers can be inhaled. Suctioning should be limited to 10-15
seconds. Ties should never be removed until the new ones are secure.
,3. A client has a pulse oximetry reading of 88% on room air. What should the
nurse do first?
A. Notify the healthcare provider immediately
B. Document the finding as normal
C. Start oxygen at 4 liters per nasal cannula
D. Assist the client into a high-Fowler position
Answer: D
Rationale: The nurse should first use a non-invasive nursing intervention, such as
repositioning the client to high-Fowler to maximize lung expansion.
4. Which oxygen delivery device provides the highest concentration of oxygen
to a spontaneously breathing patient?
A. Simple face mask
B. Non-rebreather mask
C. Nasal cannula
D. Venturi mask
Answer: B
Rationale: A non-rebreather mask with a reservoir bag can deliver oxygen concentrations
of 60% to 90%.
5. A nurse is suctioning an endotracheal tube. Which action should the nurse
take to prevent hypoxemia during the procedure?
A. Suctioning for 20 seconds
B. Hyperoxygenating the client before and after
C. Applying suction while inserting the catheter
D. Setting the suction pressure to 200 mmHg
Answer: B
Rationale: Hyperoxygenation (100% oxygen) helps prevent suction-induced hypoxemia.
Suction should only be applied while withdrawing and should not exceed 15 seconds.
, 6. A client is diagnosed with hypokalemia. Which food should the nurse
encourage the client to eat?
A. Baked potatoes with skins
B. Canned corn
C. White bread
D. Applesauce
Answer: A
Rationale: Potatoes, especially the skins, are high in potassium. Applesauce and white
bread are low in potassium.
7. Which acid-base imbalance is most likely in a client with prolonged vomiting?
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
Answer: A
Rationale: Vomiting results in the loss of gastric hydrochloric acid, leading to an increase
in serum bicarbonate and metabolic alkalosis.
8. The nurse notes a client has pitting edema in the lower extremities and
crackles in the lungs. Which condition is most likely?
A. Hypovolemia
B. Hyponatremia
C. Hypervolemia
D. Hypocalcemia
Answer: C
Rationale: Edema and pulmonary crackles are classic signs of fluid volume excess
(hypervolemia).
|Chamberlain College
1. Which assessment finding is the earliest sign of hypoxia in a client?
A. Cyanosis
B. Restlessness
C. Bradycardia
D. Decreased respiratory rate
Answer: B
Rationale: Restlessness and apprehension are the earliest signs of hypoxia. Cyanosis and
changes in heart rate or respiratory rate are often late signs.
2. When performing tracheostomy care, which action by the nurse is correct?
A. Removing the old ties before securing the new ones
B. Cutting a 4x4 gauze pad to place around the stoma
C. Suctioning the patient for 30 seconds at a time
D. Cleaning the inner cannula with hydrogen peroxide then rinsing with sterile saline
Answer: D
Rationale: The inner cannula is cleaned with half-strength peroxide and rinsed with saline.
Gauze should not be cut as fibers can be inhaled. Suctioning should be limited to 10-15
seconds. Ties should never be removed until the new ones are secure.
,3. A client has a pulse oximetry reading of 88% on room air. What should the
nurse do first?
A. Notify the healthcare provider immediately
B. Document the finding as normal
C. Start oxygen at 4 liters per nasal cannula
D. Assist the client into a high-Fowler position
Answer: D
Rationale: The nurse should first use a non-invasive nursing intervention, such as
repositioning the client to high-Fowler to maximize lung expansion.
4. Which oxygen delivery device provides the highest concentration of oxygen
to a spontaneously breathing patient?
A. Simple face mask
B. Non-rebreather mask
C. Nasal cannula
D. Venturi mask
Answer: B
Rationale: A non-rebreather mask with a reservoir bag can deliver oxygen concentrations
of 60% to 90%.
5. A nurse is suctioning an endotracheal tube. Which action should the nurse
take to prevent hypoxemia during the procedure?
A. Suctioning for 20 seconds
B. Hyperoxygenating the client before and after
C. Applying suction while inserting the catheter
D. Setting the suction pressure to 200 mmHg
Answer: B
Rationale: Hyperoxygenation (100% oxygen) helps prevent suction-induced hypoxemia.
Suction should only be applied while withdrawing and should not exceed 15 seconds.
, 6. A client is diagnosed with hypokalemia. Which food should the nurse
encourage the client to eat?
A. Baked potatoes with skins
B. Canned corn
C. White bread
D. Applesauce
Answer: A
Rationale: Potatoes, especially the skins, are high in potassium. Applesauce and white
bread are low in potassium.
7. Which acid-base imbalance is most likely in a client with prolonged vomiting?
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
Answer: A
Rationale: Vomiting results in the loss of gastric hydrochloric acid, leading to an increase
in serum bicarbonate and metabolic alkalosis.
8. The nurse notes a client has pitting edema in the lower extremities and
crackles in the lungs. Which condition is most likely?
A. Hypovolemia
B. Hyponatremia
C. Hypervolemia
D. Hypocalcemia
Answer: C
Rationale: Edema and pulmonary crackles are classic signs of fluid volume excess
(hypervolemia).
