NR-224 Fundamentals – Skills - Set 3 - Part 1

Correct Answer: Cover the site with gauze taped on three sides

Taping an occlusive dressing on three sides makes a flutter valve: air trapped in the pleural space escapes through the open edge on expiration, but none is drawn in on inspiration. The nurse stays and calls for help. Option b is incorrect because sealing all four edges closes the pleural space completely. If air continues to leak from the injured lung with no route out, pressure builds and a tension pneumothorax follows within minutes. Option c is incorrect because a wet cloth is neither sterile nor occlusive, and moisture wicks organisms straight into the wound. The site needs sterile gauze or petroleum gauze kept ready at the bedside for exactly this event. Option d is incorrect because a gloved hand cannot form the one-way barrier this client needs and occupies the nurse who must also assess and summon help. Firm pressure also seals the tract as completely as four-sided tape would.

Correct Answer: "I will use a water based gel for dryness."

Water soluble products are safe around oxygen because they do not burn. Petroleum based products are flammable and can cause lipoid pneumonia if aspirated, so they are avoided for the lips and nares. Option a is incorrect because petroleum jelly is an oil based product that ignites readily in an oxygen enriched environment. Its use on the lips or nares of a client receiving oxygen is specifically prohibited. Option b is incorrect because wool and synthetic fabrics build static charge, and a single spark can start a fire where oxygen is flowing. Cotton bedding and clothing are the recommended alternative for home use. Option d is incorrect because a space heater is a heat source, and oxygen equipment must stay at least five feet away from anything that produces heat. Warmth can come from cotton layers instead.

Correct Answer: Go assess the client's breath sounds and effort

When assistive personnel report a respiratory finding, the nurse goes and looks. Auscultation and evaluation of work of breathing cannot be delegated, and rattly breathing with refused spirometry suggests retained secretions needing assessment now. Option b is incorrect because handing the follow up back to the aide leaves the reported finding unassessed. An aide may encourage the device again, but only after the nurse determines what the breath sounds actually show. Option c is incorrect because documentation records what was found, and nothing has been found yet. Charting a refusal without evaluating the client turns a warning sign into a line in the record and nothing more. Option d is incorrect because a standing suction order is never appropriate; the decision to suction rests on assessment findings at that moment. Independent measures such as coughing, deep breathing and repositioning have not even been attempted yet.

Correct Answer: An early compensation for falling volume

Cardiac output is defended by raising heart rate when stroke volume falls, so a rising thready pulse with cool skin and low urine output signals developing hypovolemia. Blood pressure changes come later. Option a is incorrect because pain does raise the rate, but it does not make the skin cool and clammy or shrink urine output. The accompanying findings point to perfusion, not to discomfort alone. Option b is incorrect because activity raises the pulse briefly and it settles with rest. A sustained climb across a shift, paired with a thready quality, describes compensation rather than exertion. Option d is incorrect because charting a presumed drug effect would delay recognition of internal bleeding or fluid loss. Nothing in the picture suggests a stimulant, and the constellation of findings demands assessment and a call.

Correct Answer: A falsely high reading from all three problems

Unsupported feet, an unsupported back and an arm below heart level each push the number up. Gravity adds hydrostatic pressure at a lowered cuff, and isometric trunk and leg work raises pressure further. Option a is incorrect because legs that hang without support raise the pressure rather than lower it. The direction is wrong, and dangling feet are only one of three errors visible in this scene. Option b is incorrect because position is a measured source of error, not a courtesy. An unsupported back alone can add five to ten points, and the other two faults compound it. Option c is incorrect because an arm resting in the lap sits below the heart, where gravity adds pressure at the cuff. Only an arm raised above heart level produces a falsely low value.

Correct Answer: Measure at set times using the same site

The pattern of a fever over time is diagnostic information, and a pattern is only real when the readings are comparable. Using one site at scheduled times lets the provider see sustained, intermittent or relapsing behavior. Option a is incorrect because switching between routes manufactures rises and falls that the client never had. An axillary reading following an oral one can look like defervescence when nothing has actually changed. Option b is incorrect because the normal and low values carry as much diagnostic weight as the spikes. An intermittent pattern is defined by the return to normal, which disappears from the record if those readings are dropped. Option d is incorrect because those words are interpretations, and vital signs are recorded as measured values. Charting a label in place of a number strips out the height and timing that the investigation depends on.

Correct Answer: Remind the client to use the spirometer

Assistive personnel may reinforce previously taught techniques and encourage a stable client to use the device. Reminding and encouraging is a standardized task that carries no assessment, interpretation or judgment. Option b is incorrect because titrating oxygen is a prescribed therapy the registered nurse controls. Changing a flow rate requires interpreting the saturation and knowing the client's target, both of which sit outside an aide's scope. Option c is incorrect because auscultation is assessment, and assessment is never delegated. Listening to breath sounds and judging whether they changed after a cough is exactly the clinical reasoning the nurse must perform personally. Option d is incorrect because initial teaching belongs to the nurse, who must also evaluate whether the client performs the technique correctly. An aide may echo instructions already given but cannot deliver the instruction itself.

Correct Answer: Raise the head of the bed upright

Sitting the client upright is immediate, independent and free, and it lets the diaphragm descend so the lungs can expand fully. Position first, then oxygen adjustment, then notification once the response is known. Option a is incorrect because the provider does need to hear about this change, but calling comes after the nurse has done something that helps. Reporting without an intervention wastes the minutes the client is struggling. Option b is incorrect because an arterial sample is a diagnostic step requiring an order and a skilled draw. Diagnostics describe the problem; they do nothing to relieve the labored breathing happening at the bedside. Option c is incorrect because titrating oxygen requires a provider order or protocol, and the mechanical restriction of lying flat is what is limiting this client. More oxygen into a compressed chest accomplishes little.

Correct Answer: Percentage of hemoglobin binding sites carrying oxygen

Pulse oximetry reports the percentage of hemoglobin binding sites occupied by oxygen. Two wavelengths of light pass through a pulsating vascular bed, and the device calculates saturation from how much of each is absorbed. Option b is incorrect because arterial oxygen tension is obtained only from an arterial blood gas, the gold standard for oxygenation. Saturation and partial pressure are related on a curve but are not the same value. Option c is incorrect because tissue delivery depends on saturation together with hemoglobin level and cardiac output. A severely anemic client can register one hundred percent while the tissues remain starved of oxygen. Option d is incorrect because the oximeter says nothing about ventilation. Carbon dioxide elimination is judged by respiratory rate and depth, end-tidal monitoring or a blood gas, never by a saturation number.

Correct Answer: Reads about one degree lower than oral

Axillary temperature samples surface tissue rather than a core structure, so it consistently reads roughly one degree Fahrenheit below an oral value. Documenting the site lets the next nurse interpret the number correctly. Option a is incorrect because it reverses the direction of the site offset. Deeper sites such as rectal and tympanic register higher numbers; the shell registers lower ones, and the axilla is the shallowest site of all. Option b is incorrect because the axilla is the outermost measurement site available and drifts with room temperature and perfusion. Treating an axillary result as equivalent to oral hides a fever that the oral scale would reveal. Option d is incorrect because rectal readings sit at the top of the site scale, not the bottom. An axillary value placed above a rectal one would invert the entire ordering that guides site selection.

Correct Answer: Reinsert a spare tube using the obturator

A mature stoma accepts a replacement tube, and the spare and obturator sit at the bedside for this event. The nurse calls for help while reinserting, using the smaller spare if the first will not pass. Option a is incorrect because the client has no airway while the nurse waits by the telephone. Help is summoned at the same time as the airway is restored, not instead of restoring it. Option b is incorrect because sealing the stoma closes the only route this client is currently breathing through. An occlusive dressing over a chest tube site serves a different purpose entirely and has no place at a tracheostomy. Option c is incorrect because compressions treat absent circulation, and this client is coughing and struggling, which means a pulse and an effort to breathe. Restoring the airway comes first and will likely prevent an arrest.

Correct Answer: The client is in respiratory distress

A normal rate does not rule out distress. Retractions, nasal flaring and accessory muscle use all show increased work of breathing, which is always abnormal and is reported regardless of the counted rate. Option a is incorrect because effort is documented alongside rate, and this effort is clearly abnormal. Judging the assessment on the number alone is exactly how deteriorating postoperative clients are missed. Option b is incorrect because respiratory compensation for metabolic alkalosis slows and shallows breathing to retain carbon dioxide. Nothing in this picture suggests an alkalotic state, and the muscles are working harder, not less. Option d is incorrect because hyperventilation raises the rate above twenty and produces deep breaths without retractions. Anxiety does not pull in the intercostal spaces or flare the nostrils; obstructed or stiff lungs do.

Correct Answer: Withdraw the catheter and deliver supplemental oxygen

Bradycardia during suctioning comes from vagal stimulation as the catheter contacts the trachea and carina, compounded by the oxygen being removed. Removing the catheter stops the stimulus at once, and oxygen restores what the pass took. Option b is incorrect because every additional second of suction deepens both the vagal response and the hypoxia driving it. The rule when a dysrhythmia appears is to stop, not to hurry through the remaining seconds. Option c is incorrect because reducing the pressure does not remove the catheter from the carina, and mechanical contact there is what triggers the vagal reflex. The client keeps losing oxygen while the nurse adjusts a dial. Option d is incorrect because summoning a team is a later step that does nothing about the cause still sitting in the airway. Withdrawal and oxygen usually resolve suction-induced bradycardia within seconds, before any team could arrive.

Correct Answer: One hundred to one hundred fifty millimeters of mercury

Adult wall suction is set between one hundred and one hundred fifty millimeters of mercury. Pressure above that range strips tracheal mucosa, causes bleeding, and pulls alveolar gas out with the secretions, worsening hypoxemia. Option a is incorrect because that range belongs to the neonate, whose airway is tiny and fragile. Set at that level for an adult, the suction is too weak to move thick secretions out of a tracheostomy. Option b is incorrect because pressures in that band are used for infants and small children. An adult with tenacious secretions will need several extra passes to clear the airway, and each pass adds hypoxia and trauma. Option c is incorrect because nothing above one hundred fifty millimeters of mercury is safe in any age group. Higher negative pressure tears mucosa and collapses alveoli without clearing secretions any faster than the correct setting does.

Correct Answer: Report the finding to the provider immediately

Good sounds on the right with diminished sounds on the left suggest the tube has advanced into the right mainstem bronchus, leaving the left lung unventilated. The tube must be repositioned, so the provider is notified at once. Option b is incorrect because secretions would not silence one entire lung field while the other remains clear. Suctioning wastes time and oxygen on a problem the catheter cannot reach, since the tube itself is misplaced. Option c is incorrect because turning does not pull a tube back out of the right mainstem bronchus. Repositioning the client may even advance it further, and only a provider adjusts the depth of an endotracheal tube. Option d is incorrect because bilateral equal breath sounds are what confirm correct placement. Charting an asymmetric finding as normal leaves a whole lung out of the circuit and delays the chest radiograph and repositioning that follow.

Correct Answer: Reposition the probe and repeat the reading

A saturation that contradicts a comfortable, well-appearing client is usually artifact. When the oximeter pulse rate does not match the palpated pulse, the waveform is unreliable, so the nurse corrects the measurement before acting on it. Option a is incorrect because oxygen treats hypoxemia the nurse has not yet confirmed. Starting therapy on an invalid number can also mask the real problem and, in some clients, is given without any indication. Option c is incorrect because the provider would be called about a finding the nurse has reason to doubt. Verification comes first when the client looks entirely well and the device disagrees with the bedside picture. Option d is incorrect because charting a suspect number puts a false value into the permanent record. Later clinicians will trend it as though it were real, and a genuine change could be missed.

Correct Answer: Apply the nonrebreather mask and monitor closely

Hypoxia kills faster than hypercapnia, so oxygen is never withheld from a client this hypoxemic. The nurse gives the concentration needed, then watches level of consciousness and respiratory rate and titrates down as saturation allows. Option a is incorrect because withholding oxygen while awaiting a call back lets a client die of the one problem the nurse can fix immediately. Notification happens alongside treatment, never instead of it. Option b is incorrect because the home setting was prescribed for a stable baseline that no longer exists. Cyanosis, confusion and a saturation in the seventies describe an emergency that a maintenance flow rate cannot correct. Option c is incorrect because a small increase through a low flow cannula cannot lift a saturation this low fast enough. Fear of carbon dioxide retention leads students to undertreat, and undertreatment is the greater danger here.

Correct Answer: Fifth intercostal space at the left midclavicular line

The apex of the adult heart sits at the fifth intercostal space in the left midclavicular line, where the left ventricle strikes the chest wall. That spot is the point of maximal impulse. Option a is incorrect because sounds heard high on the chest near the sternum come from the great vessels, not from the ventricular apex. That position gives valve sounds but not a dependable apical rate. Option b is incorrect because the fourth intercostal space is the apex location in a young child, and the anterior axillary line sits lateral to the correct vertical landmark. Both parts of this answer miss the adult apex. Option d is incorrect because a spot that high and that close to the sternum lies over the atria and outflow tracts. Counting there risks a faint or misleading rate before a drug that depends on an accurate number.

Correct Answer: Assess further for infection and notify the provider

Older adults mount a blunted febrile response, so a low-grade reading with new confusion and poor intake may be the only evidence of infection. The nurse gathers more assessment data and reports the change promptly. Option b is incorrect because comfort offered in place of assessment lets a treatable infection advance. The family needs an explanation of why this number matters in an older adult, not agreement that it is meaningless. Option c is incorrect because delaying until the next round wastes the window in which sepsis is most reversible. New confusion is itself an acute change in condition and is an indication to assess now. Option d is incorrect because fluids treat one consequence of fever while ignoring its source. Postponing evaluation for a full day in a resident who has stopped eating and become confused is not a safe plan.

Correct Answer: Sudden confusion with slurred speech

Altered mental status is the finding that separates the two. Heat exhaustion leaves the runner oriented, while confusion signals that thermoregulation has failed and the brain is being injured by the core temperature. Option a is incorrect because sweating with cool pale skin fits heat exhaustion, where cooling still works. Sweating does not rule out heat stroke, since a runner with exertional heat stroke is often still moist. Mental status is the discriminator. Option b is incorrect because cramping reflects sodium and water losses from sweating and appears in mild heat illness. Painful calves are uncomfortable but say nothing about whether the brain is still functioning normally. Option c is incorrect because thirst and low urine output describe volume depletion, which both conditions share. Those findings track hydration, not the neurological failure that turns a heat illness into an emergency.