NR-224 Fundamentals – Skills - Set 3 - Part 2

Correct Answer: A nonrebreather mask at fifteen liters

The nonrebreather with intact one way valves and an inflated reservoir delivers roughly sixty to ninety percent oxygen at ten to fifteen liters per minute, the highest concentration available without positive pressure. Option a is incorrect because the Venturi mask is chosen for precision rather than quantity, and it tops out near fifty to sixty percent. Its value lies in controlled delivery for the client who must not be over oxygenated. Option b is incorrect because a simple mask reaches only about thirty five to fifty percent oxygen, which leaves this client short of what the emergency demands. It suits transport and brief moderate needs. Option d is incorrect because a face tent fits loosely under the chin and cannot seal, so its delivered concentration stays imprecise and moderate. Facial burns or claustrophobia justify it, but severe hypoxemia does not.

Correct Answer: Lower the flow and reassess saturation and alertness

A saturation above the ordered range means the client is receiving more oxygen than needed, which raises the risk of carbon dioxide retention. The nurse titrates the flow down and rechecks saturation and level of consciousness. Option a is incorrect because a reading well above the prescribed range is a deviation, not a normal finding to record. Charting an out of range value without adjusting the therapy ignores the order the provider wrote. Option c is incorrect because stopping oxygen outright can drop this client far below the target within minutes. Titration means small adjustments with reassessment, and an hour without monitoring leaves too much room for deterioration. Option d is incorrect because a higher number is not a better number for this client. Pushing saturation upward increases dead space through released hypoxic vasoconstriction and displaces carbon dioxide from hemoglobin, driving the level higher.

Correct Answer: The rate and depth of respirations

Breathing is partly under voluntary control, so a client who knows it is being counted alters rate and depth. Leaving the fingers on the wrist keeps the client unaware and preserves an accurate respiratory count. Option a is incorrect because pulse strength is graded while the fingers actively palpate the artery, not afterward. The nurse has already finished that part of the assessment and is now watching chest movement. Option b is incorrect because rhythm regularity is determined during the pulse count itself, and observing the chest adds nothing to it. Continued contact with the wrist serves a different purpose entirely here. Option d is incorrect because a pulse deficit requires two nurses counting the apical and radial rates at the same moment. One nurse watching the chest cannot generate that comparison.

Correct Answer: Thready, graded as one plus

A pulse that is hard to find and obliterates under light pressure is weak or thready, documented as one plus. The scale used should be noted, since texts differ about which grade counts as normal. Option a is incorrect because a grade of zero is reserved for a pulse that cannot be felt at all, even with careful searching. This pulse was found, which changes both the grade and the urgency. Option b is incorrect because an expected pulse is easily located and holds up against light palpation. Anything that vanishes the moment the fingers press is diminished, and calling it normal hides a perfusion problem. Option c is incorrect because a bounding pulse sits at the opposite end of the scale. It is forceful, cannot be obliterated, and suggests increased stroke volume or reduced vascular resistance rather than a weak one.

Correct Answer: Apply high-flow oxygen by non-rebreather mask

Carboxyhemoglobin absorbs light almost like oxyhemoglobin, so a standard oximeter counts it as saturated and reads falsely normal. The priority is high-flow oxygen by non-rebreather, which speeds carbon monoxide clearance, followed by a blood level. Option b is incorrect because reassurance rests on a number that is meaningless in this exposure. The client's confusion, headache and nausea after a fire describe poisoning, and the device cannot detect it. Option c is incorrect because moving the probe will simply produce the same falsely reassuring result. No amount of troubleshooting makes a two-wavelength device tell carbon monoxide apart from oxygen on the hemoglobin. Option d is incorrect because watching a saturation that cannot fall delays treatment while the poisoning progresses. Carbon monoxide has a half-life of hours on room air, and every minute without treatment matters.

Correct Answer: "I need to keep the container upright and below my chest."

The drainage unit stays upright so the water seal keeps its one-way function, and below chest level so gravity moves drainage away from the client rather than letting it siphon back into the pleural space. Option a is incorrect because lifting the unit to chest height removes the gravity gradient the system depends on. Fluid already collected can run back toward the pleural space, and drainage from the chest slows or stops. Option c is incorrect because a lap is well above the insertion site once the client is seated. The unit hangs from the chair or the bed frame, never resting on the client or on the mattress. Option d is incorrect because a dependent loop fills with fluid and creates a column that opposes drainage and raises pressure in the system. Excess tubing is coiled flat beside the client so it runs straight downhill.

Correct Answer: Coarse rhonchi heard over the large airways

Coarse rhonchi over the large airways mean secretions the client cannot clear are sitting where a catheter can reach them. Suctioning is indicated by assessment findings like this one, never by the clock. Option b is incorrect because vesicular sounds throughout the lung fields are the normal finding, meaning air is moving freely and no secretions are obstructing the airway. Suctioning this client would injure healthy mucosa. Option c is incorrect because a client who coughs secretions out effectively has already done what the catheter would do. Coaching and encouraging that cough is the intervention here, and suction stays in reserve. Option d is incorrect because that saturation sits within the expected range and gives no evidence of retained secretions. A falling saturation would support suctioning; a stable normal one argues against putting a catheter into the airway.

Correct Answer: Call for help and prepare for airway support

A client who was struggling and is now calm, drowsy and slow is tiring and retaining carbon dioxide. A chest that has gone silent means air is no longer moving, and respiratory arrest is near. Option a is incorrect because charting improvement here records the opposite of what is happening. Wheezing that stops without treatment signals collapsing airflow, and drowsiness in a previously agitated client marks exhaustion rather than recovery. Option b is incorrect because comfort measures suit a client who is genuinely settling, and this one is decompensating. Leaving the room to promote rest removes the observer at the precise moment continuous watching matters most. Option d is incorrect because cutting oxygen from a failing client accelerates the collapse already underway. Waiting an hour also abandons a client whose breathing has slowed and whose air movement has nearly stopped.

Correct Answer: The brachial artery of the arm

In an infant younger than one year the brachial pulse is the site checked during resuscitation, because the short neck makes the carotid hard to locate. The check takes no more than ten seconds. Option a is incorrect because the carotid is the resuscitation site for adults and for children older than one year. An infant neck is short and fatty, and hunting for that landmark wastes seconds. Option b is incorrect because peripheral pulses are unreliable in infants and vanish early when cardiac output falls. Feeling nothing at the wrist would say little about whether the heart is still ejecting blood. Option c is incorrect because the temporal site serves as a convenient alternative for routine counting in children, not as an emergency check. It is too far from a central artery to guide a resuscitation decision.

Correct Answer: Secretions sitting in the larger airways

Rhonchi are low pitched coarse sounds produced by secretions in the large airways, and they characteristically clear or change after an effective cough. That response points toward coughing and deep breathing rather than a bronchodilator. Option a is incorrect because alveolar fluid produces crackles, which are discontinuous popping sounds heard mainly on inspiration. Crackles caused by fluid or fibrosis persist after coughing, and these sounds disappeared. Option c is incorrect because bronchospasm generates wheezes, continuous musical whistling that is loudest on expiration and does not clear when the client coughs. Treating this finding as bronchospasm would send the nurse toward the wrong intervention. Option d is incorrect because a pleural friction rub grates on both inspiration and expiration, is often painful, and stays unchanged with coughing. Nothing about a sound that vanishes after one cough fits inflamed pleura.

Correct Answer: A pattern of Kussmaul respirations

Kussmaul respirations are deep, rapid and labored breaths that blow off carbon dioxide to compensate for metabolic acidosis. Diabetic ketoacidosis is the classic cause, and the fruity odor comes from ketones. Option a is incorrect because Cheyne-Stokes breathing cycles from shallow to deep and back again, ending each cycle in a pause of apnea. Heart failure and rising intracranial pressure produce it, not ketoacidosis. Option b is incorrect because ataxic breathing appears as irregular clusters of breaths separated by unpredictable pauses, with no build and taper. It points toward brainstem injury or meningitis rather than a metabolic cause. Option c is incorrect because hypoventilation means shallow breaths that retain carbon dioxide and drive respiratory acidosis. This client is moving large volumes of air, which is the opposite finding.

Correct Answer: Remove the candle and explain the fire risk

Oxygen does not burn but it strongly supports combustion, so any open flame near an oxygen source can ignite bedding, clothing and hair. Open flames are removed, never merely relocated or ventilated. Option a is incorrect because the five foot rule applies to heaters, stoves and radiators, not to a live flame. An oxygen enriched room makes distance an inadequate safeguard against ignition. Option c is incorrect because ventilation does not lower the oxygen concentration in the fabrics, hair and skin surrounding a client on continuous therapy. Those saturated materials are exactly what ignites when a flame is nearby. Option d is incorrect because a heating device introduces a second ignition source rather than eliminating the first one. Electrical appliances that spark or generate heat carry their own hazard in an oxygen enriched environment.

Correct Answer: Bypasses the nose and pharynx entirely

Air normally enters through the nose and pharynx, which warm, filter and moisten it. A tracheostomy sends dry gas straight into the trachea, so added humidity is what keeps secretions thin enough to be coughed or suctioned out. Option b is incorrect because water vapor changes nothing about the concentration of oxygen delivered. The flow rate and the device determine how much oxygen the client receives; the humidifier only conditions the gas on its way in. Option c is incorrect because skin care around the stoma is handled by cleaning, drying and the pre-cut dressing. Humidification is aimed at the secretions inside the trachea, not at the surface of the neck. Option d is incorrect because pressure regulation is not a function of the humidifier at all. Gas pressure is set by the flowmeter, and adding moisture to that gas leaves the delivered pressure exactly where it was.

Correct Answer: Cover the client and give the antipyretic

Shivering marks the chill phase, when the set point has jumped and actual temperature is still climbing toward it. Warming stops the shivering, and the antipyretic lowers the set point the body is chasing. Option a is incorrect because stripping covers from a client who already feels cold drives harder shivering. Each shivering episode multiplies heat production and oxygen demand, pushing the temperature higher rather than bringing it down. Option b is incorrect because physical cooling is reserved for hyperthermia or a dangerously high fever that antipyretics have not touched. Applied during a rising fever it widens the gap the body is trying to close. Option d is incorrect because a cooling blanket removes heat by direct contact, which is precisely the stimulus that triggers the shivering reflex. That device belongs to a client whose set point is normal.

Correct Answer: Activate emergency services and stay with the client

Severe hypertension with chest pain, severe headache and visual change is a hypertensive emergency, meaning target organ damage is under way. The client needs emergency transport, intravenous therapy and continuous monitoring, and must not be left alone. Option a is incorrect because resting and rechecking is the response to severe hypertension in a client with no symptoms. Symptoms of organ injury remove that option and convert the situation into an emergency. Option c is incorrect because a next-day appointment suits hypertensive urgency, where the pressure is lowered gradually over hours to days. Chest pain and visual change cannot wait that long without risking infarction or stroke. Option d is incorrect because an oral dose works too slowly for an emergency and dropping the pressure abruptly causes cerebral, cardiac and renal ischemia. Titrated intravenous therapy under monitoring is what this client requires.

Correct Answer: Reports the finding and anticipates active rewarming

Shivering fails as the core drops toward the moderate range, so its loss with lethargy and bradycardia signals worsening hypothermia. Passive measures are no longer enough, and active rewarming with continuous monitoring is needed. Option a is incorrect because the end of shivering is loss of the body's last internal heat source, not evidence of recovery. Charting it as progress delays the escalation this client already needs. Option b is incorrect because friction massage on a cold limb is unsafe. Rough handling can trigger ventricular fibrillation in a chilled heart, and warming the periphery first sends cold blood inward and drops the core further. Option c is incorrect because anything given by mouth threatens the airway of a client who cannot be roused. Warm drinks belong to an alert person with mild cooling, not to one whose consciousness is falling.

Correct Answer: Schedule the session before the midday meal

Chest physiotherapy is performed before meals or at least one to two hours afterward, because the positions and percussion provoke nausea, vomiting and aspiration on a full stomach. Each position is usually held ten to fifteen minutes. Option b is incorrect because head down positions and chest percussion immediately after eating invite vomiting and aspiration. Waiting one to two hours after a meal is the minimum interval, and before the meal is preferable. Option c is incorrect because percussion is never applied over the spine, sternum, kidneys, breasts, incisions or fractured ribs. Those areas cover structures that bruise or injure easily, so the therapy targets the affected lung segment only. Option d is incorrect because one minute gives gravity almost no time to move secretions toward the central airways. Positions are typically maintained ten to fifteen minutes and are followed by coughing or huffing.

Correct Answer: Positioning the client upright for the meal tray

Positioning is a standardized task assistive personnel can carry out once the nurse has decided the client sits upright to eat. Teaching, swallowing evaluation and stoma assessment all require nursing judgment and stay with the nurse. Option a is incorrect because initial teaching of any technique belongs to the nurse, who must also evaluate how well the client uses it. Assistive personnel may only remind and encourage a method already taught. Option b is incorrect because judging swallowing safety is an assessment, and a client with a fresh tracheostomy carries real aspiration risk. Someone without that training would not recognize a silent aspiration when it happened. Option d is incorrect because inspecting the stoma for redness, drainage, odor or crepitus is respiratory assessment. Every aspect of tracheostomy site care is retained by the nurse, no matter how routine it looks.

Correct Answer: Stimulate the client and withhold further opioids

Bradypnea with shallow breathing and sedation after an opioid signals respiratory depression. The nurse stimulates the client, holds further doses, applies oxygen, keeps naloxone available and notifies the provider before the rate falls further. Option a is incorrect because charting alone leaves an actively deteriorating client unattended. Documentation follows intervention in every emergent respiratory situation, and this rate demands action at the bedside right now. Option c is incorrect because waiting an hour allows the sedation to deepen while carbon dioxide climbs. Opioid-induced respiratory depression progresses quickly, and a rate of eight is already below the reportable threshold. Option d is incorrect because incentive spirometry needs an awake, cooperative client who can follow directions. A client who is difficult to rouse cannot perform it, and the drug effect must be reversed first.

Correct Answer: I will wear layers and keep a hat on indoors.

Layered clothing traps warm air and a head covering blocks the radiation losses that strip heat fastest. Older adults have thin subcutaneous fat and a weak vasomotor response, so environmental measures carry much of the protection. Option b is incorrect because alcohol dilates surface vessels and creates a false sensation of warmth while heat pours out through the skin. It also clouds judgment, and both effects raise the risk of hypothermia. Option c is incorrect because the sensation of warmth is unreliable in old age, when thermoreceptors and the thirst and shivering responses all dull. Extra insulation stays on regardless of how comfortable the room feels. Option d is incorrect because shivering is an attempt to generate heat against a falling core, so it warns that the body is losing ground. Reading it as reassurance leads a client to stay in a cold room.