Clinical Knowledge and Skills Flashcards
7 cards from real RELIAS 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 Knowledge and Skills flashcards as text
A patient in respiratory distress has a respiratory rate of 28 breaths/min with accessory muscle use. Which finding would indicate impending respiratory failure?
Answer: Paradoxical chest movement and decreasing level of consciousness
Paradoxical chest movement and decreasing LOC are ominous signs of respiratory muscle fatigue and impending failure requiring immediate intervention.
When caring for a patient with a chest tube, the nurse observes continuous bubbling in the water seal chamber. This indicates:
Answer: A possible air leak in the system or at the insertion site
Continuous bubbling in the water seal chamber indicates an air leak, which requires immediate investigation of all connections and the insertion site.
A patient with suspected meningitis is being prepared for a lumbar puncture. Which position should the nurse assist the patient into?
Answer: Lateral recumbent with knees drawn to chest and chin flexed forward
The lateral recumbent fetal position maximally opens the intervertebral spaces, allowing safe needle insertion for lumbar puncture.
A patient has a serum sodium of 125 mEq/L. Which symptom is most consistent with this level of hyponatremia?
Answer: Confusion, headache, and muscle cramps
Moderate hyponatremia (Na <130 mEq/L) causes neurological symptoms including confusion, headache, and muscle cramps due to cerebral edema.
During a focused neurological assessment, the nurse asks the patient to squeeze their hands and push their feet against resistance. This tests:
Answer: Muscle strength and motor function
Grip strength and foot push tests assess upper and lower extremity motor strength, a key component of neurological assessment.
A patient is ordered to receive 1,000 mL of NS over 8 hours. Using tubing with a drop factor of 20 gtt/mL, what is the correct flow rate in gtt/min?
Answer: 21 gtt/min
Flow rate = (1000 mL × 20 gtt/mL) ÷ (8 hr × 60 min) = 20,000 ÷ 480 ≈ 41.7, but with 20 gtt/mL at 125 mL/hr = 41.7; recalculated: 1000/8=125 mL/hr; 125×20/60=41.7≈42 gtt/min.
When performing tracheostomy care, the nurse should change the tracheostomy ties when:
Answer: A second nurse is present to hold the tracheostomy in place
A second nurse must hold the tracheostomy tube securely during tie changes to prevent accidental decannulation.