Clinical Flashcards
7 cards from real NMC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Clinical flashcards as text
A nurse assesses a peripheral IV site and finds redness, warmth, swelling, and pain along the vein. On the Visual Infusion Phlebitis (VIP) scale, what grade does this represent?
Answer: Grade 2 — early phlebitis
Grade 2 on the VIP scale is characterized by pain, erythema, and swelling at the IV site, indicating early phlebitis.
Under NMC record-keeping standards, which elements are REQUIRED in all nursing documentation?
Answer: Date, time, full signature, and legible clear content
NMC standards require all records to be dated, timed, clearly written, and signed by the accountable nurse.
When collecting blood via venepuncture using a vacutainer system, what is the correct ORDER of draw?
Answer: Blood culture bottles → coagulation tubes → EDTA tubes
Blood culture bottles are drawn first to prevent contamination, followed by coagulation tubes, then EDTA tubes.
A patient receiving IV heparin for 6 days develops a new rash and their platelet count falls to 42,000/mm³. What condition should the nurse suspect?
Answer: Heparin-Induced Thrombocytopenia (HIT)
HIT typically presents 5–10 days after heparin initiation with thrombocytopenia and requires immediate cessation of heparin.
A patient on long-term warfarin has an INR of 6.5 and is not actively bleeding. What is the MOST appropriate nursing action?
Answer: Hold warfarin and notify the physician
A supratherapeutic INR without bleeding requires holding warfarin and medical review; IV vitamin K and FFP are reserved for active bleeding.
A patient is in the immediate post-anesthesia care unit (PACU) following general anesthesia. What is the HIGHEST priority assessment in the first 30 minutes?
Answer: Airway patency and respiratory status
Airway obstruction and respiratory depression are the leading causes of post-anesthesia mortality, making airway the top priority.
Twenty minutes into a blood transfusion, a patient develops rigors, a temperature of 39.3°C, and lower back pain. What should the nurse do FIRST?
Answer: Stop the transfusion immediately and maintain IV access with normal saline
Signs of a transfusion reaction require immediate cessation of the transfusion while IV access is maintained for emergency treatment.