Relias Clinical Knowledge and Skills 3 — Questions and Answers
Question 1: A patient receiving a blood transfusion develops fever, chills, and back pain 15 minutes after initiation. What is the priority nursing action?
- Slow the transfusion rate and administer acetaminophen
- Stop the transfusion immediately and maintain IV access with normal saline (Correct answer)
- Switch to a different blood unit
- Administer diphenhydramine and continue monitoring
Correct answer: Stop the transfusion immediately and maintain IV access with normal saline
Signs of a transfusion reaction require immediately stopping the transfusion while maintaining IV access for emergency medications.
Question 2: Which wound characteristic indicates a stage 3 pressure injury?
- Intact skin with non-blanchable redness
- Partial-thickness skin loss involving the dermis
- Full-thickness tissue loss without exposed bone, tendon, or muscle (Correct answer)
- Full-thickness tissue loss with exposed bone or muscle
Correct answer: Full-thickness tissue loss without exposed bone, tendon, or muscle
Stage 3 pressure injuries involve full-thickness tissue loss that may include subcutaneous fat but without exposed underlying structures.
Question 3: A patient has a serum potassium of 2.8 mEq/L. Which clinical manifestation would you most likely assess?
- Muscle weakness and leg cramps (Correct answer)
- Peaked T waves on ECG
- Slow, irregular respirations
- Hyperreflexia and tetany
Correct answer: Muscle weakness and leg cramps
Hypokalemia commonly causes muscle weakness and cramping due to altered cell membrane excitability.
Question 4: When administering a subcutaneous injection of heparin, the nurse should:
- Aspirate before injecting to confirm placement
- Inject into the abdomen 2 inches from the umbilicus and do not rub the site (Correct answer)
- Massage the site vigorously after injection to promote absorption
- Use a 1-inch needle at a 90-degree angle
Correct answer: Inject into the abdomen 2 inches from the umbilicus and do not rub the site
Heparin subcutaneous injections in the abdomen avoid the umbilicus; rubbing the site is avoided to prevent bruising and hematoma formation.
Question 5: A patient on long-term corticosteroid therapy should be monitored for which metabolic complication?
- Hypoglycemia and weight loss
- Hyperglycemia and Cushing's syndrome features (Correct answer)
- Hypocalcemia and hyperphosphatemia
- Hyperthyroidism and tachycardia
Correct answer: Hyperglycemia and Cushing's syndrome features
Long-term corticosteroids cause hyperglycemia by promoting gluconeogenesis and insulin resistance, along with classic Cushing's features.
Question 6: A patient's pain is rated 8/10 and opioids are ordered. Before administering, the nurse should assess which parameter?
- Blood pressure and heart rate
- Respiratory rate and level of consciousness (Correct answer)
- Temperature and skin integrity
- Bowel sounds and last bowel movement
Correct answer: Respiratory rate and level of consciousness
Opioids can cause respiratory depression; assessing respiratory rate and LOC before administration ensures patient safety.
Question 7: Which technique best verifies nasogastric tube placement before feeding?
- Auscultating over the stomach while injecting air
- Aspirating gastric contents and confirming pH ≤5.5 via pH paper (Correct answer)
- Observing for bubbling when the tube end is placed in water
- Asking the patient if they feel the tube in their stomach
Correct answer: Aspirating gastric contents and confirming pH ≤5.5 via pH paper
Aspirating gastric contents and testing pH ≤5.5 is the most reliable bedside method to confirm gastric placement of an NG tube.
Relias Clinical Knowledge and Skills 3
A patient receiving a blood transfusion develops fever, chills, and back pain 15 minutes after initiation.
What is the priority nursing action?