Relias Clinical Knowledge and Skills 3

Question 1

A patient receiving a blood transfusion develops fever, chills, and back pain 15 minutes after initiation. What is the priority nursing action?

Accepted Answer

Stop the transfusion immediately and maintain IV access with normal saline

Answer

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?

Accepted Answer

Full-thickness tissue loss without exposed bone, tendon, or muscle

Answer

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?

Accepted Answer

Muscle weakness and leg cramps

Answer

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:

Accepted Answer

Inject into the abdomen 2 inches from the umbilicus and do not rub the site

Answer

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?

Accepted Answer

Hyperglycemia and Cushing's syndrome features

Answer

Long-term corticosteroids cause hyperglycemia by promoting gluconeogenesis and insulin resistance, along with classic Cushing's features.

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