NR224 EXAM 2 QUESTIONS AND
CORRECT ANSWERS VERIFIED
AND GRADED A+
1. A nurse is assessing a client who has an acute respiratory infection,
increasing the risk for hypoxemia. Which of the following findings are early
indications that should alert the nurse that the client is developing hypoxia?
(Select all that apply.)
A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Hypertension
A. Restlessness
B. Tachypnea
D. Confusion
E. Hypertension
2. A provider is discharging a client who has a prescription for home oxygen
therapy via nasal cannula. Client and family teaching by the nurse should
include which of the following instructions? (Select all that apply.)
A. Apply petroleum jelly around and inside the nares.
B. Remove the nasal cannula during mealtimes.
,C. Check the position of the cannula frequently.
D. Report any nausea or difficulty breathing.
E. Post "No Smoking" signs in prominent locations
C. Check the position of the cannula frequently.
D. Report any nausea or difficulty breathing.
E. Post "No Smoking" signs in prominent locations
3. A nurse is caring for a client who is having difficulty breathing. The client is
lying in bed and is already receiving oxygen therapy via nasal cannula.
Which of the following interventions is the nurse's priority?
A. Increase the oxygen flow.
B. Assist the client to Fowler's position.
C. Promote removal of pulmonary secretions.
D. Obtain a specimen for arterial blood gases
B. Assist the client to Fowler's position.
4. A nurse is preparing to perform endotracheal suctioning for a client. The
nurse should follow which of the following guidelines? (Select all that apply.)
A. Apply suction while withdrawing the catheter.
B. Perform suctioning on a routine basis every 2 to 3 hr.
C. Maintain medical asepsis during suctioning.
D. Use a new catheter for each suctioning attempt.
E. Apply suction for 10 to 15 seconds.
A. Apply suction while withdrawing the catheter.
,D. Use a new catheter for each suctioning attempt.
E. Apply suction for 10 to 15 seconds.
5. A nurse is caring for a client who has a tracheostomy. Which of the
following actions should the nurse take when providing tracheostomy care?
(Select all that apply.)
A. Apply the oxygen source loosely if the SpO2 decreases during the
procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer cannula surfaces in a circular motion from the stoma site
outward.
D. Replace the tracheostomy ties with new ties.
E. Cut a slit in gauze squares to place beneath the tube holder.
A. Apply the oxygen source loosely if the SpO2 decreases during the
procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer cannula surfaces in a circular motion from the
stoma site outward.
1. A nurse is teaching a client who reports stress urinary incontinence. Which
of the following instructions should the nurse include? (Select all that apply.)
A. Limit total daily fluid intake.
B. Decrease or avoid caffeine.
C. Take calcium supplements.
D. Avoid drinking alcohol.
, E. Use the Credé maneuver
B. Decrease or avoid caffeine.
D. Avoid drinking alcohol.
2. A client who has an indwelling catheter reports a need to urinate. Which of
the following actions should the nurse take?
A. Check to see whether the catheter is patent.
B. Reassure the client that it is not possible for them to urinate.
C. Recatheterize the bladder with a larger-gauge catheter.
D. Collect a urine specimen for analysis.
A. Check to see whether the catheter is patent.
A clogged or kinked catheter causes the bladder to fill and stimulates the
need to urinate.
3. A nurse is caring for a client who has a prescription for a 24-hr urine
collection. Which of the following actions should the nurse take?
A. Discard the first voiding.
B. Keep the urine in a single container at room temperature.
C. Dispose of the last voiding.
D. Ask the client to urinate into the toilet, stop midstream, and finish
urinating into the specimen container
A. Discard the first voiding.
CORRECT ANSWERS VERIFIED
AND GRADED A+
1. A nurse is assessing a client who has an acute respiratory infection,
increasing the risk for hypoxemia. Which of the following findings are early
indications that should alert the nurse that the client is developing hypoxia?
(Select all that apply.)
A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Hypertension
A. Restlessness
B. Tachypnea
D. Confusion
E. Hypertension
2. A provider is discharging a client who has a prescription for home oxygen
therapy via nasal cannula. Client and family teaching by the nurse should
include which of the following instructions? (Select all that apply.)
A. Apply petroleum jelly around and inside the nares.
B. Remove the nasal cannula during mealtimes.
,C. Check the position of the cannula frequently.
D. Report any nausea or difficulty breathing.
E. Post "No Smoking" signs in prominent locations
C. Check the position of the cannula frequently.
D. Report any nausea or difficulty breathing.
E. Post "No Smoking" signs in prominent locations
3. A nurse is caring for a client who is having difficulty breathing. The client is
lying in bed and is already receiving oxygen therapy via nasal cannula.
Which of the following interventions is the nurse's priority?
A. Increase the oxygen flow.
B. Assist the client to Fowler's position.
C. Promote removal of pulmonary secretions.
D. Obtain a specimen for arterial blood gases
B. Assist the client to Fowler's position.
4. A nurse is preparing to perform endotracheal suctioning for a client. The
nurse should follow which of the following guidelines? (Select all that apply.)
A. Apply suction while withdrawing the catheter.
B. Perform suctioning on a routine basis every 2 to 3 hr.
C. Maintain medical asepsis during suctioning.
D. Use a new catheter for each suctioning attempt.
E. Apply suction for 10 to 15 seconds.
A. Apply suction while withdrawing the catheter.
,D. Use a new catheter for each suctioning attempt.
E. Apply suction for 10 to 15 seconds.
5. A nurse is caring for a client who has a tracheostomy. Which of the
following actions should the nurse take when providing tracheostomy care?
(Select all that apply.)
A. Apply the oxygen source loosely if the SpO2 decreases during the
procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer cannula surfaces in a circular motion from the stoma site
outward.
D. Replace the tracheostomy ties with new ties.
E. Cut a slit in gauze squares to place beneath the tube holder.
A. Apply the oxygen source loosely if the SpO2 decreases during the
procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer cannula surfaces in a circular motion from the
stoma site outward.
1. A nurse is teaching a client who reports stress urinary incontinence. Which
of the following instructions should the nurse include? (Select all that apply.)
A. Limit total daily fluid intake.
B. Decrease or avoid caffeine.
C. Take calcium supplements.
D. Avoid drinking alcohol.
, E. Use the Credé maneuver
B. Decrease or avoid caffeine.
D. Avoid drinking alcohol.
2. A client who has an indwelling catheter reports a need to urinate. Which of
the following actions should the nurse take?
A. Check to see whether the catheter is patent.
B. Reassure the client that it is not possible for them to urinate.
C. Recatheterize the bladder with a larger-gauge catheter.
D. Collect a urine specimen for analysis.
A. Check to see whether the catheter is patent.
A clogged or kinked catheter causes the bladder to fill and stimulates the
need to urinate.
3. A nurse is caring for a client who has a prescription for a 24-hr urine
collection. Which of the following actions should the nurse take?
A. Discard the first voiding.
B. Keep the urine in a single container at room temperature.
C. Dispose of the last voiding.
D. Ask the client to urinate into the toilet, stop midstream, and finish
urinating into the specimen container
A. Discard the first voiding.
