Trivium Clinical Skills and Procedures 3 — Questions and Answers
Question 1: A patient receiving a blood transfusion develops sudden chills, fever, and back pain 15 minutes into the infusion. What is the priority action?
- Slow the infusion rate and monitor closely
- Stop the transfusion, keep the IV line open with normal saline, and notify the provider (Correct answer)
- Administer acetaminophen and continue the transfusion
- Switch to the next unit of blood
Correct answer: Stop the transfusion, keep the IV line open with normal saline, and notify the provider
Signs of an acute hemolytic reaction require immediately stopping the transfusion while maintaining IV access with normal saline and notifying the provider.
Question 2: Which finding indicates that a patient's chest tube is functioning correctly?
- Constant bubbling in the water-seal chamber
- Intermittent bubbling in the water-seal chamber with respirations (Correct answer)
- No fluctuation (tidaling) in the water-seal chamber
- Air leak visible in the suction control chamber only
Correct answer: Intermittent bubbling in the water-seal chamber with respirations
Tidaling — intermittent fluctuation in the water-seal chamber that corresponds with respirations — indicates a patent, properly functioning chest tube.
Question 3: What is the correct hand placement for two-handed bag-valve-mask ventilation?
- Both hands squeeze the bag while a second rescuer holds the mask with one hand
- One hand forms a C-E clamp on the mask while the other squeezes the bag; a second provider squeezes the bag (Correct answer)
- Both thumbs press down on the mask while fingers lift the jaw
- One hand holds the mask, the other holds the patient's head
Correct answer: One hand forms a C-E clamp on the mask while the other squeezes the bag; a second provider squeezes the bag
Two-person BVM technique has one rescuer maintain a C-E clamp seal on the mask while the second rescuer compresses the bag, improving mask seal and tidal volume.
Question 4: A nurse is removing sutures from a healing wound. Which assessment finding would contraindicate suture removal?
- Suture line intact with minimal redness
- Wound edges well-approximated and dry
- Signs of wound dehiscence or incomplete healing (Correct answer)
- Sutures present for the expected number of days post-op
Correct answer: Signs of wound dehiscence or incomplete healing
Dehiscence or evidence of inadequate healing indicates the wound cannot yet support itself without sutures, and removal should be delayed.
Question 5: When performing a 12-lead ECG, where is the V1 electrode placed?
- 4th intercostal space, left sternal border
- 4th intercostal space, right sternal border (Correct answer)
- 5th intercostal space, midclavicular line
- 2nd intercostal space, right sternal border
Correct answer: 4th intercostal space, right sternal border
V1 is placed at the 4th intercostal space on the right sternal border, serving as the reference point for the remaining precordial leads.
Question 6: A patient's IV site is swollen, cool, and pale with a slowed infusion rate. These findings indicate:
- Phlebitis
- Infiltration (Correct answer)
- Thrombosis
- Air embolism
Correct answer: Infiltration
Infiltration occurs when IV fluid leaks into surrounding tissue, causing swelling, pallor, and coolness at the site with a slowed or stopped infusion.
Question 7: Which is the correct method to measure the length for nasogastric tube insertion?
- Ear to nose to xiphoid process
- Nose to ear to mid-sternum
- Nose to ear to xiphoid process (Correct answer)
- Nose to clavicle to navel
Correct answer: Nose to ear to xiphoid process
The NEX measurement (Nose–Ear–Xiphoid process) estimates the length needed to place the tube tip in the stomach.
Trivium Clinical Skills and Procedures 3
A patient receiving a blood transfusion develops sudden chills, fever, and back pain 15 minutes into the infusion.
What is the priority action?