NMC Clinical 5

Question 1

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?

Accepted Answer

Grade 2 — early phlebitis

Answer

Grade 0 — no symptoms

Answer

Grade 4 — advanced thrombophlebitis

Answer

Grade 1 — possible first sign

Question 2

Under NMC record-keeping standards, which elements are REQUIRED in all nursing documentation?

Accepted Answer

Date, time, full signature, and legible clear content

Answer

First name and shift only

Answer

Abbreviations are encouraged to save time

Answer

Documentation can be completed on the following shift

Question 3

When collecting blood via venepuncture using a vacutainer system, what is the correct ORDER of draw?

Accepted Answer

Blood culture bottles → coagulation tubes → EDTA tubes

Answer

EDTA tubes → coagulation tubes → blood culture bottles

Answer

Coagulation tubes → blood culture bottles → EDTA tubes

Answer

Serum separator tubes → coagulation tubes → blood culture bottles

Question 4

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?

Accepted Answer

Heparin-Induced Thrombocytopenia (HIT)

Answer

Expected heparin effect requiring no action

Answer

Allergic reaction requiring antihistamine only

Answer

Anemia secondary to blood loss

Question 5

A patient on long-term warfarin has an INR of 6.5 and is not actively bleeding. What is the MOST appropriate nursing action?

Accepted Answer

Hold warfarin and notify the physician

Answer

Administer IV vitamin K immediately

Answer

Continue warfarin and recheck in 24 hours

Answer

Administer fresh frozen plasma (FFP)

Question 6

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?

Accepted Answer

Airway patency and respiratory status

Answer

Pain score using NRS

Answer

Urinary output measurement

Answer

Wound site inspection

Question 7

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?

Accepted Answer

Stop the transfusion immediately and maintain IV access with normal saline

Answer

Slow the infusion rate and closely monitor the patient

Answer

Administer paracetamol and continue the transfusion

Answer

Contact the blood bank before stopping the transfusion