Relias Clinical Knowledge and Skills 2 — Questions and Answers
Question 1: A nurse notices a patient's SpO2 drops to 88% while sleeping. What is the most appropriate initial intervention?
- Administer 100% oxygen via non-rebreather mask
- Apply supplemental oxygen at 2-4 L/min via nasal cannula and reassess (Correct answer)
- Immediately intubate the patient
- Wake the patient and instruct them to breathe deeply
Correct answer: Apply supplemental oxygen at 2-4 L/min via nasal cannula and reassess
Initial supplemental oxygen via nasal cannula and reassessment is appropriate for mild hypoxia before escalating interventions.
Question 2: When performing a capillary blood glucose check, which site is preferred for an adult patient?
- The fingertip center pad
- The lateral aspect of the fingertip (Correct answer)
- The earlobe
- The forearm
Correct answer: The lateral aspect of the fingertip
The lateral aspect of the fingertip has fewer nerve endings, causing less pain while still providing an adequate blood sample.
Question 3: A patient is prescribed vancomycin. Which lab value must be monitored to prevent nephrotoxicity?
- Serum potassium
- Serum creatinine and BUN (Correct answer)
- Liver enzymes (AST/ALT)
- Complete blood count
Correct answer: Serum creatinine and BUN
Vancomycin is nephrotoxic, so serum creatinine and BUN must be monitored to detect renal impairment early.
Question 4: Which assessment finding in a post-operative patient warrants immediate notification of the physician?
- Pain score of 4/10 at the incision site
- Urine output of 20 mL over 2 hours (Correct answer)
- Temperature of 99.2°F on postoperative day 1
- Mild nausea without vomiting
Correct answer: Urine output of 20 mL over 2 hours
Urine output less than 30 mL/hour indicates oliguria and potential renal hypoperfusion requiring urgent intervention.
Question 5: A patient with COPD is receiving oxygen therapy. The nurse should titrate oxygen to maintain SpO2 at which target range?
- 98-100%
- 95-98%
- 88-92% (Correct answer)
- 80-85%
Correct answer: 88-92%
COPD patients may rely on hypoxic drive; SpO2 88-92% prevents both hypoxia and suppression of the respiratory drive.
Question 6: When inserting a urinary catheter in a female patient, which step is critical to prevent infection?
- Using the smallest catheter size available
- Cleansing the urethral meatus with antiseptic solution before insertion (Correct answer)
- Inflating the balloon before confirming placement
- Clamping the catheter immediately after insertion
Correct answer: Cleansing the urethral meatus with antiseptic solution before insertion
Cleansing the urethral meatus with antiseptic solution before insertion is a key aseptic technique to prevent catheter-associated UTI.
Question 7: A patient's ECG shows a prolonged PR interval (>0.20 seconds). This finding is consistent with which condition?
- Ventricular fibrillation
- First-degree AV block (Correct answer)
- Bundle branch block
- Atrial flutter
Correct answer: First-degree AV block
A PR interval greater than 0.20 seconds indicates delayed conduction through the AV node, characteristic of first-degree AV block.
Relias Clinical Knowledge and Skills 2
A nurse notices a patient's SpO2 drops to 88% while sleeping.
What is the most appropriate initial intervention?