Clinical Flashcards

A patient's oxygen saturation drops to 88%. Which action should the nurse take FIRST?

Answer: Administer supplemental oxygen and reassess

An SpO2 of 88% is below the acceptable range (94–98%) and requires immediate supplemental oxygen followed by reassessment.

When assessing a pressure injury where subcutaneous fat is visible but no bone, tendon, or muscle is exposed, how should it be staged?

Answer: Stage III

Stage III pressure injuries involve full-thickness skin loss with visible subcutaneous tissue but no exposed underlying structures.

Which pain assessment tool is MOST appropriate for a patient who is sedated and unable to self-report pain?

Answer: Behavioral Pain Scale (BPS)

The Behavioral Pain Scale assesses pain through observable behaviors in non-verbal or unconscious patients.

A nurse obtains a blood glucose reading of 2.8 mmol/L on a conscious patient. What is the PRIORITY nursing action?

Answer: Administer oral glucose and recheck in 15 minutes

A blood glucose below 4.0 mmol/L indicates hypoglycemia; conscious patients should receive fast-acting oral glucose immediately.

When performing a central venous catheter (CVC) dressing change, which PPE is REQUIRED to maintain aseptic technique?

Answer: Sterile gloves and surgical mask

CVC dressing changes require sterile gloves and a surgical mask to maintain asepsis and prevent central line-associated bloodstream infection.

What is the RECOMMENDED method for confirming nasogastric tube placement before administering feed?

Answer: pH testing of aspirate, confirming pH ≤5.5

pH testing of gastric aspirate (pH ≤5.5) is the recommended and safe method for confirming nasogastric tube placement.

A patient has a Glasgow Coma Scale (GCS) score of 3. What does this indicate?

Answer: No eye opening, no verbal response, and no motor response

A GCS of 3 is the minimum possible score, indicating complete unresponsiveness across all three components.