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 2 on the VIP scale is characterized by pain, erythema, and swelling at the IV site, indicating early phlebitis.

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

NMC standards require all records to be dated, timed, clearly written, and signed by the accountable nurse.

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

Blood culture bottles are drawn first to prevent contamination, followed by coagulation tubes, then EDTA tubes.

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

HIT typically presents 5–10 days after heparin initiation with thrombocytopenia and requires immediate cessation of heparin.

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

A supratherapeutic INR without bleeding requires holding warfarin and medical review; IV vitamin K and FFP are reserved for active bleeding.

(NMC) Nursing Midwifery Council Practice Test

(NMC) Nursing Midwifery Council Practice Test

NMC Clinical 5