NMC Clinical 2 — Questions and Answers
Question 1: A patient's oxygen saturation drops to 88%. Which action should the nurse take FIRST?
- Administer supplemental oxygen and reassess (Correct answer)
- Document the finding and continue monitoring
- Call the physician before taking any action
- Reposition the patient's finger on the probe
Correct 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.
Question 2: When assessing a pressure injury where subcutaneous fat is visible but no bone, tendon, or muscle is exposed, how should it be staged?
- Stage III (Correct answer)
- Stage I
- Stage II
- Stage IV
Correct answer: Stage III
Stage III pressure injuries involve full-thickness skin loss with visible subcutaneous tissue but no exposed underlying structures.
Question 3: Which pain assessment tool is MOST appropriate for a patient who is sedated and unable to self-report pain?
- Behavioral Pain Scale (BPS) (Correct answer)
- Numeric Rating Scale (NRS)
- Wong-Baker FACES scale
- Visual Analog Scale (VAS)
Correct answer: Behavioral Pain Scale (BPS)
The Behavioral Pain Scale assesses pain through observable behaviors in non-verbal or unconscious patients.
Question 4: A nurse obtains a blood glucose reading of 2.8 mmol/L on a conscious patient. What is the PRIORITY nursing action?
- Administer oral glucose and recheck in 15 minutes (Correct answer)
- Notify the physician and wait for orders
- Administer the patient's next scheduled insulin dose
- Document and recheck in 30 minutes
Correct 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.
Question 5: When performing a central venous catheter (CVC) dressing change, which PPE is REQUIRED to maintain aseptic technique?
- Sterile gloves and surgical mask (Correct answer)
- Clean gloves only
- Apron and clean gloves
- No PPE is required
Correct 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.
Question 6: What is the RECOMMENDED method for confirming nasogastric tube placement before administering feed?
- pH testing of aspirate, confirming pH ≤5.5 (Correct answer)
- Auscultating the abdomen while injecting air
- Measuring the external tube length
- Visual inspection of tube position
Correct 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.
Question 7: A patient has a Glasgow Coma Scale (GCS) score of 3. What does this indicate?
- No eye opening, no verbal response, and no motor response (Correct answer)
- Mild confusion with eye opening to voice
- Moderate impairment with localizing pain
- Eyes open spontaneously with confused speech
Correct 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.
NMC Clinical 2
A patient's oxygen saturation drops to 88%.
Which action should the nurse take FIRST?