NMC CBT Nursing Practice and Decision Making 1 — Questions and Answers
Question 1: You are caring for a patient who is receiving intravenous (IV) fluids and develops redness and swelling at the IV insertion site. What is your first action?
- Increase the flow rate of the IV fluids.
- Remove the IV and assess for signs of infection. (Correct answer)
- Administer pain medication and continue the IV fluids.
- Apply a warm compress and monitor the site.
Correct answer: Remove the IV and assess for signs of infection.
Redness and swelling at an IV insertion site are signs of potential complications such as phlebitis or infiltration. The immediate and safest action is to remove the IV catheter to prevent further tissue damage or infection. After removal, the site should be assessed for the severity of the complication and appropriate interventions initiated.
Question 2: A patient in your care has a blood pressure of 180/110 mmHg. What should you do next?
- Reassure the patient that the reading is within normal limits.
- Record the reading and wait to see if the pressure lowers on its own.
- Inform the doctor and monitor the patient for signs of a hypertensive crisis. (Correct answer)
- Administer antihypertensive medication without consulting the doctor.
Correct answer: Inform the doctor and monitor the patient for signs of a hypertensive crisis.
A blood pressure reading of 180/110 mmHg is significantly elevated and indicates a hypertensive urgency or emergency, requiring prompt medical attention. The nurse's immediate responsibility is to report this critical finding to the doctor. Continuous monitoring for signs of a hypertensive crisis, such as headache or vision changes, is essential to prevent serious complications.
Question 3: A patient with diabetes is complaining of dizziness and sweating. Their blood sugar level is 50 mg/dL. What is your immediate action?
- Administer a dose of insulin to regulate their blood sugar.
- Give the patient a sugary drink or snack. (Correct answer)
- Ask the patient to lie down and rest.
- Monitor the patient for further symptoms and wait for the doctor’s orders.
Correct answer: Give the patient a sugary drink or snack.
Dizziness and sweating with a blood sugar level of 50 mg/dL are classic symptoms of hypoglycemia, a medical emergency. The immediate action is to administer a fast-acting carbohydrate, such as a sugary drink or snack, to rapidly raise blood glucose levels. This intervention is critical to prevent further deterioration and potential loss of consciousness.
Question 4: A patient with a known allergy to penicillin is prescribed an antibiotic containing penicillin. What should you do?
- Administer the antibiotic as prescribed, as allergies do not always cause severe reactions.
- Contact the prescribing doctor to clarify the medication and inform them of the allergy. (Correct answer)
- Delay administering the antibiotic and wait for the patient to confirm the allergy.
- Inform the patient about the medication and proceed with administration.
Correct answer: Contact the prescribing doctor to clarify the medication and inform them of the allergy.
Administering a medication to which a patient has a known allergy can lead to a severe, life-threatening allergic reaction. It is the nurse's professional and ethical responsibility to always verify medication orders against patient allergies. Contacting the prescribing doctor to clarify the order and inform them of the allergy is a critical safety measure before administering any medication.
Question 5: You are about to perform a procedure on a patient and need to obtain consent. What should you do?
- Obtain verbal consent before proceeding with the procedure.
- Proceed with the procedure without consent if it is an emergency.
- Ensure the patient fully understands the procedure, risks, and benefits, and obtain written consent if necessary. (Correct answer)
- Obtain consent from the patient's family member if the patient is unable to provide consent.
Correct answer: Ensure the patient fully understands the procedure, risks, and benefits, and obtain written consent if necessary.
Informed consent is a fundamental ethical and legal principle in healthcare, ensuring patient autonomy. It requires the patient to fully understand the procedure, including its purpose, potential risks, benefits, and available alternatives, before agreeing to it. The nurse's role is to ensure this understanding and obtain appropriate consent, often written for invasive procedures, to protect the patient's rights.
NMC CBT Nursing Practice and Decision Making 1
You are caring for a patient who is receiving intravenous (IV) fluids and develops redness and swelling at the IV insertion site.
What is your first action?