NMC Clinical 2

Question 1

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

Accepted Answer

Administer supplemental oxygen and reassess

Answer

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?

Accepted Answer

Stage III

Answer

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?

Accepted Answer

Behavioral Pain Scale (BPS)

Answer

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?

Accepted Answer

Administer oral glucose and recheck in 15 minutes

Answer

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?

Accepted Answer

Sterile gloves and surgical mask

Answer

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

(NMC) Nursing Midwifery Council Practice Test