NR 224 Fundamentals of Nursing Week 7 Study Guide 2026
|Chamberlain College
1. Which assessment finding is a late sign of hypoxia in a client with respiratory
distress?
A. Tachycardia
B. Cyanosis
C. Restlessness
D. Tachypnea
Answer: B
Rationale: Cyanosis is considered a late sign of hypoxia, whereas restlessness, tachycardia,
and tachypnea are early signs as the body attempts to compensate.
2. When performing tracheal suctioning, what is the maximum duration for each
suction pass?
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 30 seconds
D. Unlimited as long as secretions are present
Answer: A
Rationale: Suctioning should be limited to 10 to 15 seconds to prevent hypoxia and vagal
stimulation.
,3. A client is prescribed oxygen via a nasal cannula at 4 L/min. Which nursing
action is essential for this flow rate?
A. Ensure the client is in a prone position.
B. Attach a humidification device.
C. Monitor for carbon dioxide narcosis.
D. Set the flow rate to 10 L/min for the first hour.
Answer: B
Rationale: Humidification is necessary for oxygen flow rates greater than 4 L/min to
prevent drying of the nasal mucosa.
4. Which breath sound is characterized by high-pitched, musical sounds heard
primarily during expiration?
A. Rhonchi
B. Wheezes
C. Crackles
D. Stridor
Answer: B
Rationale: Wheezes are high-pitched musical sounds caused by air passing through
narrowed airways, commonly heard in asthma.
5. When instructing a patient on the use of an incentive spirometer, the nurse
should tell the patient to:
A. Exhale forcefully into the device.
B. Hold their breath for 30 seconds after inhalation.
C. Use the device once every 4 hours while awake.
D. Inhale slowly and deeply through the mouthpiece.
Answer: D
Rationale: The incentive spirometer encourages deep breathing through slow, steady
inhalation to expand alveoli.
, 6. A nurse is suctioning a client’s oropharynx. Which action should the nurse
take first?
A. Perform hand hygiene and apply clean gloves.
B. Apply suction while inserting the catheter.
C. Insert the catheter 10 inches into the throat.
D. Hyperoxygenate the client for 5 minutes.
Answer: A
Rationale: Hand hygiene and gloving are the first steps to prevent infection before
performing oropharyngeal suctioning.
7. What is the primary purpose of pursed-lip breathing for a patient with COPD?
A. To increase the respiratory rate.
B. To decrease the amount of oxygen reaching the lungs.
C. To strengthen the intercostal muscles.
D. To promote carbon dioxide elimination by preventing airway collapse.
Answer: D
Rationale: Pursed-lip breathing creates back pressure in the airways, keeping them open
longer to allow more CO2 to be exhaled.
8. A nurse is caring for a patient with a chest tube. Which finding requires
immediate intervention?
A. Drainage of 50 mL of serosanguinous fluid in 8 hours.
B. Intermittent bubbling in the water-seal chamber during coughing.
C. Fluctuation of water level with inspiration (tidaling).
D. Constant bubbling in the water-seal chamber.
Answer: D
Rationale: Constant bubbling in the water-seal chamber indicates an air leak in the system,
which is an abnormal finding.
|Chamberlain College
1. Which assessment finding is a late sign of hypoxia in a client with respiratory
distress?
A. Tachycardia
B. Cyanosis
C. Restlessness
D. Tachypnea
Answer: B
Rationale: Cyanosis is considered a late sign of hypoxia, whereas restlessness, tachycardia,
and tachypnea are early signs as the body attempts to compensate.
2. When performing tracheal suctioning, what is the maximum duration for each
suction pass?
A. 10 to 15 seconds
B. 5 seconds
C. 20 to 30 seconds
D. Unlimited as long as secretions are present
Answer: A
Rationale: Suctioning should be limited to 10 to 15 seconds to prevent hypoxia and vagal
stimulation.
,3. A client is prescribed oxygen via a nasal cannula at 4 L/min. Which nursing
action is essential for this flow rate?
A. Ensure the client is in a prone position.
B. Attach a humidification device.
C. Monitor for carbon dioxide narcosis.
D. Set the flow rate to 10 L/min for the first hour.
Answer: B
Rationale: Humidification is necessary for oxygen flow rates greater than 4 L/min to
prevent drying of the nasal mucosa.
4. Which breath sound is characterized by high-pitched, musical sounds heard
primarily during expiration?
A. Rhonchi
B. Wheezes
C. Crackles
D. Stridor
Answer: B
Rationale: Wheezes are high-pitched musical sounds caused by air passing through
narrowed airways, commonly heard in asthma.
5. When instructing a patient on the use of an incentive spirometer, the nurse
should tell the patient to:
A. Exhale forcefully into the device.
B. Hold their breath for 30 seconds after inhalation.
C. Use the device once every 4 hours while awake.
D. Inhale slowly and deeply through the mouthpiece.
Answer: D
Rationale: The incentive spirometer encourages deep breathing through slow, steady
inhalation to expand alveoli.
, 6. A nurse is suctioning a client’s oropharynx. Which action should the nurse
take first?
A. Perform hand hygiene and apply clean gloves.
B. Apply suction while inserting the catheter.
C. Insert the catheter 10 inches into the throat.
D. Hyperoxygenate the client for 5 minutes.
Answer: A
Rationale: Hand hygiene and gloving are the first steps to prevent infection before
performing oropharyngeal suctioning.
7. What is the primary purpose of pursed-lip breathing for a patient with COPD?
A. To increase the respiratory rate.
B. To decrease the amount of oxygen reaching the lungs.
C. To strengthen the intercostal muscles.
D. To promote carbon dioxide elimination by preventing airway collapse.
Answer: D
Rationale: Pursed-lip breathing creates back pressure in the airways, keeping them open
longer to allow more CO2 to be exhaled.
8. A nurse is caring for a patient with a chest tube. Which finding requires
immediate intervention?
A. Drainage of 50 mL of serosanguinous fluid in 8 hours.
B. Intermittent bubbling in the water-seal chamber during coughing.
C. Fluctuation of water level with inspiration (tidaling).
D. Constant bubbling in the water-seal chamber.
Answer: D
Rationale: Constant bubbling in the water-seal chamber indicates an air leak in the system,
which is an abnormal finding.
