NHI Patient Care and Procedures 5 — Questions and Answers
Question 1: A healthcare worker notices a patient's IV site is cool, pale, and swollen. This indicates:
- Phlebitis
- Infiltration (Correct answer)
- Infection
- Normal IV function
Correct answer: Infiltration
Cool, pale, and swollen skin at an IV site indicates infiltration, meaning fluid is leaking into surrounding tissue rather than the vein.
Question 2: When applying a sterile dressing, the healthcare worker accidentally touches the sterile field with an ungloved hand. The correct action is:
- Continue if only the edge was touched
- Wipe the touched area with an alcohol swab and continue
- Stop, discard contaminated supplies, and start over with new sterile supplies (Correct answer)
- Blow on the area to remove contaminants
Correct answer: Stop, discard contaminated supplies, and start over with new sterile supplies
Any contact with a non-sterile object renders the sterile field contaminated; all contaminated supplies must be discarded and the procedure restarted.
Question 3: During tracheostomy suctioning, the maximum suctioning time per pass should not exceed:
- 5 seconds
- 10-15 seconds (Correct answer)
- 30 seconds
- 60 seconds
Correct answer: 10-15 seconds
Each suction pass should be limited to 10-15 seconds to prevent hypoxia, trauma, and cardiac arrhythmias.
Question 4: A patient in Buck's traction for a hip fracture must be positioned with the affected leg:
- Internally rotated and adducted
- In external rotation with pillow between legs
- In maintained alignment without rotation (Correct answer)
- Elevated above the level of the heart
Correct answer: In maintained alignment without rotation
Buck's traction requires the leg to remain in maintained alignment without rotation to achieve proper fracture stabilization.
Question 5: Which action is correct when performing oral hygiene on an unconscious patient?
- Place the patient supine to allow easy access
- Position the patient in lateral position with head turned to the side (Correct answer)
- Use a toothbrush with toothpaste and standard amount of water
- Perform oral care every 8 hours only
Correct answer: Position the patient in lateral position with head turned to the side
The lateral position with the head turned to the side allows fluid to drain out of the mouth, preventing aspiration in an unconscious patient.
Question 6: A patient prescribed ear drops should be positioned with the affected ear:
- Facing downward to allow drainage before instillation
- Facing upward, and remain in that position for 5 minutes after instillation (Correct answer)
- At 45 degrees with head tilted away from the affected ear
- Facing forward with head straight
Correct answer: Facing upward, and remain in that position for 5 minutes after instillation
Turning the affected ear upward before and after instillation allows drops to flow into the ear canal and remain in contact with the eardrum.
Question 7: Which change in a patient's condition requires the healthcare worker to STOP the activity and notify the nurse immediately?
- Pulse increasing from 72 to 80 during ambulation
- Patient reports mild muscle fatigue during exercise
- Patient becomes diaphoretic and complains of chest pain during ambulation (Correct answer)
- Respiratory rate increasing from 14 to 18 during activity
Correct answer: Patient becomes diaphoretic and complains of chest pain during ambulation
Diaphoresis combined with chest pain during activity are classic warning signs of cardiac ischemia and require immediate cessation of activity and nurse notification.
NHI Patient Care and Procedures 5
A healthcare worker notices a patient's IV site is cool, pale, and swollen.
This indicates: