NR224 Exam 3 Actual Exam Style V3 | NR
224 Fundamentals - Skills | Chamberlain
1. A nurse is suctioning a client’s tracheostomy. Which action should the nurse take to
prevent hypoxia during the procedure?
A. Apply continuous suction while inserting the catheter.
B. Limit suctioning to no more than 10 to 15 seconds per pass.
C. Suction the client every 2 hours routinely.
D. Maintain a suction pressure between 150 and 200 mmHg.
Correct Answer: B
Expert Explanation: Limiting suctioning to 10-15 seconds prevents prolonged periods of
oxygen deprivation and potential cardiac arrest. The nurse should also hyperoxygenate the
client with 100 percent oxygen before and after the procedure to bolster oxygen reserves.
Suction should only be applied intermittently during withdrawal to avoid mucosal damage
and further hypoxia.
2. The nurse is caring for a client with a chest tube. What should the nurse do if the chest
tube becomes accidentally disconnected from the drainage system?
A. Submerge the end of the tube in 2 cm of sterile water.
B. Cover the insertion site with a sterile occlusive dressing.
C. Clamp the chest tube immediately with two padded hemostats.
,D. Instruct the client to perform a Valsalva maneuver.
Correct Answer: A
Expert Explanation: Submerging the end of the tube in sterile water creates a water seal
that prevents air from entering the pleural space while a new drainage system is prepared.
Clamping is generally avoided as it increases the risk of a tension pneumothorax. The nurse
must act quickly to maintain the integrity of the vacuum system to ensure lung re-
expansion.
3. When performing tracheostomy care, which action by the nurse is essential for maintaining
safety?
A. Remove the old ties before securing the new ones.
B. Keep a spare tracheostomy tube of the same size at the bedside.
C. Use clean technique to clean the inner cannula.
D. Clean the stoma with hydrogen peroxide and leave it wet.
Correct Answer: B
Expert Explanation: Keeping a spare tracheostomy kit at the bedside is critical for
emergency re-insertion in case of accidental decannulation. New ties should always be
secured before old ties are removed to prevent the tube from being coughed out. The
procedure requires sterile technique to prevent healthcare-associated infections like
pneumonia.
, 4. A nurse is assessing a patient who is 2 days post-operative. Which finding most likely
indicates the development of atelectasis?
A. Productive cough with yellow sputum.
B. Diminished breath sounds in the lung bases.
C. Increased tactile fremitus over the upper lobes.
D. Oxygen saturation of 96% on room air.
Correct Answer: B
Expert Explanation: Diminished breath sounds in the bases indicate that the alveoli are
collapsed or not fully expanding, which is characteristic of atelectasis. This condition often
occurs post-operatively due to shallow breathing and lack of movement. Nursing
interventions like incentive spirometry and early ambulation are key to preventing this
complication.
5. A client is prescribed a Venturi mask at 40% FiO2. What is the primary benefit of using this
specific oxygen delivery device?
A. It provides a precise concentration of oxygen regardless of respiratory rate.
B. It can deliver high concentrations of oxygen up to 100%.
C. It allows the patient to eat and speak without interruption.
D. It is the most comfortable device for long-term home use.
Correct Answer: A
224 Fundamentals - Skills | Chamberlain
1. A nurse is suctioning a client’s tracheostomy. Which action should the nurse take to
prevent hypoxia during the procedure?
A. Apply continuous suction while inserting the catheter.
B. Limit suctioning to no more than 10 to 15 seconds per pass.
C. Suction the client every 2 hours routinely.
D. Maintain a suction pressure between 150 and 200 mmHg.
Correct Answer: B
Expert Explanation: Limiting suctioning to 10-15 seconds prevents prolonged periods of
oxygen deprivation and potential cardiac arrest. The nurse should also hyperoxygenate the
client with 100 percent oxygen before and after the procedure to bolster oxygen reserves.
Suction should only be applied intermittently during withdrawal to avoid mucosal damage
and further hypoxia.
2. The nurse is caring for a client with a chest tube. What should the nurse do if the chest
tube becomes accidentally disconnected from the drainage system?
A. Submerge the end of the tube in 2 cm of sterile water.
B. Cover the insertion site with a sterile occlusive dressing.
C. Clamp the chest tube immediately with two padded hemostats.
,D. Instruct the client to perform a Valsalva maneuver.
Correct Answer: A
Expert Explanation: Submerging the end of the tube in sterile water creates a water seal
that prevents air from entering the pleural space while a new drainage system is prepared.
Clamping is generally avoided as it increases the risk of a tension pneumothorax. The nurse
must act quickly to maintain the integrity of the vacuum system to ensure lung re-
expansion.
3. When performing tracheostomy care, which action by the nurse is essential for maintaining
safety?
A. Remove the old ties before securing the new ones.
B. Keep a spare tracheostomy tube of the same size at the bedside.
C. Use clean technique to clean the inner cannula.
D. Clean the stoma with hydrogen peroxide and leave it wet.
Correct Answer: B
Expert Explanation: Keeping a spare tracheostomy kit at the bedside is critical for
emergency re-insertion in case of accidental decannulation. New ties should always be
secured before old ties are removed to prevent the tube from being coughed out. The
procedure requires sterile technique to prevent healthcare-associated infections like
pneumonia.
, 4. A nurse is assessing a patient who is 2 days post-operative. Which finding most likely
indicates the development of atelectasis?
A. Productive cough with yellow sputum.
B. Diminished breath sounds in the lung bases.
C. Increased tactile fremitus over the upper lobes.
D. Oxygen saturation of 96% on room air.
Correct Answer: B
Expert Explanation: Diminished breath sounds in the bases indicate that the alveoli are
collapsed or not fully expanding, which is characteristic of atelectasis. This condition often
occurs post-operatively due to shallow breathing and lack of movement. Nursing
interventions like incentive spirometry and early ambulation are key to preventing this
complication.
5. A client is prescribed a Venturi mask at 40% FiO2. What is the primary benefit of using this
specific oxygen delivery device?
A. It provides a precise concentration of oxygen regardless of respiratory rate.
B. It can deliver high concentrations of oxygen up to 100%.
C. It allows the patient to eat and speak without interruption.
D. It is the most comfortable device for long-term home use.
Correct Answer: A
