Next Practice and Application 3 — Questions and Answers
Question 1: A nurse is caring for a patient on a ventilator. The high-pressure alarm sounds. What is the first action?
- Silence the alarm and document it
- Assess the patient and check tubing for obstruction (Correct answer)
- Increase the FiO2 setting
- Call the respiratory therapist immediately
Correct answer: Assess the patient and check tubing for obstruction
The nurse must first assess the patient and check for causes such as secretions, kinked tubing, or biting of the tube.
Question 2: A client with COPD is receiving oxygen therapy. Which oxygen delivery method is most appropriate to maintain a controlled FiO2?
- Simple face mask
- Nonrebreather mask
- Venturi mask (Correct answer)
- Nasal cannula at 6 L/min
Correct answer: Venturi mask
The Venturi mask delivers a precise, controlled FiO2, which is critical for COPD patients who rely on a hypoxic drive.
Question 3: A nurse is inserting a urinary catheter in a female patient. After the catheter is inserted and urine begins to flow, what is the next step?
- Inflate the balloon with sterile water (Correct answer)
- Remove the catheter and reinsert 2 cm further
- Secure the catheter to the inner thigh
- Connect the catheter to the drainage bag
Correct answer: Inflate the balloon with sterile water
Once urine flow is confirmed, the retention balloon is inflated to secure the catheter in the bladder.
Question 4: A nurse is caring for a patient with a new colostomy. Which stool characteristic indicates the ostomy is functioning appropriately for a sigmoid colostomy?
- Liquid, green output
- Formed or semi-formed stool (Correct answer)
- Bloody, mucoid discharge
- No output for the first 24 hours
Correct answer: Formed or semi-formed stool
A sigmoid colostomy is located near the end of the colon, so output should be formed or semi-formed like normal stool.
Question 5: A patient is admitted with suspected pulmonary embolism. Which assessment finding is most consistent with this diagnosis?
- Bradycardia and hypotension
- Sudden onset dyspnea and pleuritic chest pain (Correct answer)
- Bilateral crackles and peripheral edema
- Productive cough with fever
Correct answer: Sudden onset dyspnea and pleuritic chest pain
Sudden dyspnea and pleuritic chest pain are classic presenting symptoms of pulmonary embolism.
Question 6: Which action by a nurse demonstrates correct use of the SBAR communication tool when transferring a patient?
- Listing all medications the patient takes
- Providing a structured report with Situation, Background, Assessment, and Recommendation (Correct answer)
- Describing the patient's family history in detail
- Reading from the entire medical record
Correct answer: Providing a structured report with Situation, Background, Assessment, and Recommendation
SBAR provides a standardized, concise communication framework that reduces errors during handoffs.
Question 7: A nurse is caring for a patient in traction. Which intervention is essential for skin integrity?
- Apply heat to the skin under the traction device
- Perform regular skin assessments under and around the device (Correct answer)
- Keep the traction weights on the bed when repositioning
- Remove the traction every 4 hours for range-of-motion exercises
Correct answer: Perform regular skin assessments under and around the device
Regular skin assessment under and around traction equipment detects pressure injuries before they worsen.
Next Practice and Application 3
A nurse is caring for a patient on a ventilator.
The high-pressure alarm sounds.
What is the first action?