Editing Nursing Skills and Procedures – RN Practice Questions

These 15 items test '''Nursing Skills and Procedures''' at registered nurse complexity: advanced psychomotor skills, complication recognition, and prioritization. Options are numbered as they render; the letter equivalent is given with each answer.

==Question 1==
A registered nurse is changing the injection cap on a client's tunneled central venous catheter when the client suddenly becomes dyspneic, hypotensive, and confused. Which action should the nurse take '''first'''?
# Administer 100 percent oxygen by nonrebreather mask.
# Clamp the catheter and place the client in the left lateral Trendelenburg position.
# Obtain a stat set of vital signs and a 12-lead electrocardiogram.
# Notify the rapid response team and the provider.

'''Answer:''' 2 (B). Clamp the catheter and place the client in the left lateral Trendelenburg position.

''Rationale:'' The presentation during an open central line manipulation is classic venous air embolism. Clamping stops further air entry, and left lateral Trendelenburg, the Durant maneuver, traps air in the apex of the right ventricle so it does not enter the pulmonary outflow tract. Oxygen in option 1 is the correct '''second''' action and helps reabsorb nitrogen, but it does not stop the ongoing air entry. Option 3 delays treatment for data collection. Option 4 is necessary but follows the immediate physical intervention the nurse can perform right now.

==Question 2==
A registered nurse is selecting a site for a peripheral intravenous catheter in an adult client. Which sites should the nurse '''avoid'''? '''Select all that apply.'''
# The forearm of the nondominant arm.
# The arm on the side of a previous mastectomy with axillary lymph node dissection.
# The arm containing an arteriovenous fistula.
# A vein just distal to a site that infiltrated yesterday.
# The dorsum of the hand in a client who is alert and ambulatory.
# The lower extremity of an ambulatory adult.

'''Answer:''' 2, 3, 4, and 6 (B, C, D, F).

''Rationale:'' Infusing into an arm with lymph node dissection risks lymphedema and infection; a fistula arm must be preserved for dialysis access; a site distal to a recent infiltration will leak because the vein above it is compromised, so the nurse moves proximal to previous attempts; and lower extremity veins in adults carry a high thrombophlebitis and embolism risk. Options 1 and 5 are acceptable choices, with the forearm generally preferred over the hand for comfort and dwell time.

==Question 3==
A client receiving a norepinephrine infusion through a peripheral intravenous catheter reports burning at the site, and the nurse notes blanching and swelling around the insertion site. Which action should the nurse take '''first'''?
# Remove the catheter and apply a warm compress.
# Stop the infusion but leave the catheter in place.
# Elevate the extremity and continue the infusion at a slower rate.
# Apply a cold compress and reassess in 30 minutes.

'''Answer:''' 2 (B). Stop the infusion but leave the catheter in place.

''Rationale:'' Norepinephrine is a vesicant, so this is extravasation, not simple infiltration. The infusion is stopped immediately, but the catheter stays in place so residual drug can be aspirated and the antidote, phentolamine, can be infiltrated through it as ordered. Option 1 removes the access needed for the antidote and is the response to a nonvesicant infiltration. Option 3 continues tissue injury. Option 4 delays care, and with vasoconstrictor extravasation warmth and vasodilation, not cold, is the goal.

==Question 4==
A registered nurse receives report on four clients. Which client should the nurse assess '''first'''?
# A client with a nasogastric feeding running who is coughing and whose oxygen saturation has fallen from 96 to 88 percent.
# A client with a stage 3 pressure injury whose dressing has serosanguineous drainage.
# A client with a new peripherally inserted central catheter awaiting confirmatory chest radiograph.
# A client one day after abdominal surgery reporting incisional pain rated 6 out of 10.

'''Answer:''' 1 (A). The client with tube feeding, coughing, and falling saturation.

''Rationale:'' Coughing with acute desaturation during enteral feeding indicates probable aspiration, an airway and breathing emergency. The nurse stops the feeding, positions the client on the side, suctions, and oxygenates. Option 2 describes expected drainage from a granulating wound. Option 3 is a client awaiting a routine verification with no reported symptoms. Option 4 is an expected postoperative finding requiring analgesia but not before an airway threat.

==Question 5==
A registered nurse reads a tuberculin skin test 72 hours after placement on a client who is receiving long-term corticosteroid therapy. The nurse palpates an area of induration measuring 7 mm surrounded by 15 mm of erythema. How should the nurse interpret this result?
# Negative, because the induration is less than 10 mm.
# Negative, because erythema is not measured.
# Positive, because 5 mm or more of induration is significant in an immunosuppressed client.
# Positive, because the total reaction including erythema exceeds 15 mm.

'''Answer:''' 3 (C). Positive, because 5 mm or more of induration is significant in an immunosuppressed client.

''Rationale:'' Only induration is measured, and the significance threshold depends on risk. Five millimeters is positive for immunosuppressed clients, including those on chronic corticosteroids, clients with human immunodeficiency virus, transplant recipients, and recent close contacts of active cases. Ten millimeters applies to other higher-risk groups and 15 mm to those with no risk factors. Options 1 and 2 apply the wrong threshold or the wrong conclusion, and option 4 incorrectly includes erythema. A positive result reflects exposure and requires follow-up chest imaging and symptom assessment, not an immediate diagnosis of active disease.

==Question 6==
A registered nurse is performing a dressing change on a client's nontunneled central venous catheter. Which actions are appropriate? '''Select all that apply.'''
# Apply a mask to self and the client, or have the client turn the head away.
# Cleanse the site with chlorhexidine using friction and allow it to air dry completely.
# Fan the site with a sterile gauze to speed drying time.
# Change the transparent dressing sooner than scheduled if it becomes damp, loose, or soiled.
# Measure the external catheter length and compare it with the documented length.
# Use a 3 mL syringe to forcefully flush a catheter with no blood return.

'''Answer:''' 1, 2, 4, and 5 (A, B, D, E).

''Rationale:'' Masking or turning the client's head protects the sterile field from respiratory droplets. Chlorhexidine kills organisms during its drying time, so full air drying is essential and fanning in option 3 both contaminates the field and defeats the antisepsis. Dressings are changed on a schedule or immediately when integrity is lost. Comparing external catheter length detects migration. Option 6 is dangerous: a small barrel generates very high pressure and can rupture the catheter or dislodge a thrombus. Absent blood return is assessed and reported, never forced.

==Question 7==
Fifteen minutes into a transfusion of packed red blood cells, a client develops chills, a temperature increase of 1.5 degrees Celsius, flank pain, and dark red urine. After stopping the transfusion, which action should the nurse take '''next'''?
# Flush the existing blood tubing with 0.9 percent sodium chloride to keep the vein open.
# Disconnect the blood tubing and infuse 0.9 percent sodium chloride through new tubing.
# Administer the prescribed antipyretic and resume the transfusion at a slower rate.
# Send the blood bag to the laboratory and document the reaction.

'''Answer:''' 2 (B). Disconnect the blood tubing and infuse 0.9 percent sodium chloride through new tubing.

''Rationale:'' This is an acute hemolytic reaction. Vascular access must be maintained for fluid resuscitation to protect the kidneys, but flushing the existing tubing as in option 1 would push additional incompatible blood into the client. New tubing is required. Option 3 is contraindicated; a transfusion is never restarted after a suspected hemolytic reaction. Option 4 is necessary but follows stabilization of the client and maintenance of access.

==Question 8==
A registered nurse is preparing to administer the first feeding through a newly inserted small-bore nasogastric tube. Which method of verifying placement is required before the initial use?
# Auscultating over the epigastrium while injecting 30 mL of air.
# Aspirating gastric contents and testing the pH.
# Reviewing the radiographic report confirming tube position.
# Asking the client to speak and observing for coughing.

'''Answer:''' 3 (C). Reviewing the radiographic report confirming tube position.

''Rationale:'' Radiographic confirmation is the gold standard and is required before the first use of a blindly inserted small-bore feeding tube, because these tubes can enter the airway without producing symptoms, particularly in sedated or neurologically impaired clients. Option 1 is unreliable and is no longer accepted practice. Option 2 is an appropriate adjunct before subsequent feedings but is not sufficient initially and is unreliable when acid-suppressing medications are given. Option 4 misses silent malposition.

==Question 9==
On the fourth postoperative day, a client who is coughing suddenly reports that "something gave way." The nurse finds a loop of bowel protruding through the abdominal incision. Which actions should the nurse take? '''Select all that apply.'''
# Cover the protruding tissue with sterile gauze moistened with sterile normal saline.
# Gently replace the bowel into the abdominal cavity.
# Position the client in low Fowler position with the knees flexed.
# Keep the client NPO and monitor for signs of shock.
# Notify the surgeon immediately.
# Apply a dry occlusive pressure dressing and tape it securely.

'''Answer:''' 1, 3, 4, and 5 (A, C, D, E).

''Rationale:'' Evisceration is a surgical emergency. Moist sterile saline gauze prevents drying and necrosis of exposed viscera. Low Fowler with flexed knees reduces abdominal wall tension and further protrusion. The client is kept NPO in anticipation of operative repair and monitored for hypovolemic shock and peritonitis, and the surgeon is notified at once. Option 2 is never done, as it introduces contamination and can injure the bowel. Option 6 applies harmful pressure and a dry dressing desiccates the tissue.

==Question 10==
A registered nurse assesses a bedbound client and finds a dry, black, firmly adherent, intact eschar over the left heel with no surrounding erythema, fluctuance, drainage, or odor. Which action is most appropriate?
# Request an order for sharp debridement of the eschar.
# Apply a hydrogel dressing to soften and remove the eschar.
# Keep the eschar dry and intact, offload the heel, and monitor for changes.
# Apply wet-to-dry gauze dressings three times daily.

'''Answer:''' 3 (C). Keep the eschar dry and intact, offload the heel, and monitor for changes.

''Rationale:'' Stable, dry, adherent eschar on an ischemic heel serves as the body's natural biological cover and should not be removed. It is documented as an unstageable pressure injury. The nursing priority is pressure redistribution with heel offloading, keeping the eschar dry, and reporting any new erythema, fluctuance, drainage, odor, or softening, which would indicate infection and change the plan. Options 1, 2, and 4 all remove or moisten the protective eschar and would expose poorly perfused tissue to infection.

==Question 11==
A client with a serum potassium of 2.8 mEq/L has an order for potassium chloride 40 mEq. Which nursing action is appropriate?
# Administer the potassium by slow intravenous push over five minutes.
# Dilute the potassium and infuse it by electronic infusion pump with cardiac monitoring.
# Add the potassium to the existing bag of intravenous fluid at the bedside and increase the rate.
# Hold the dose and request an oral formulation because intravenous potassium is contraindicated.

'''Answer:''' 2 (B). Dilute the potassium and infuse it by electronic infusion pump with cardiac monitoring.

''Rationale:'' Intravenous potassium is never given by push or bolus at any rate; it causes cardiac arrest. It is always diluted, administered by pump within institutional concentration and rate limits, and accompanied by monitoring of the site, the cardiac rhythm, and urine output, since potassium is renally excreted. Option 3 risks a layered, concentrated dose and is outside safe practice. Option 4 is incorrect, because intravenous replacement is appropriate for significant hypokalemia; the nurse should also assess the magnesium level, since hypomagnesemia makes hypokalemia refractory to replacement.

==Question 12==
A registered nurse must administer 3 mL of a viscous intramuscular antibiotic to an adult client. Which site should the nurse select, and how should the injection be given?
# Deltoid, at a 90 degree angle, without Z-track.
# Dorsogluteal, at a 90 degree angle, using Z-track.
# Ventrogluteal, at a 90 degree angle, using Z-track.
# Vastus lateralis, at a 45 degree angle, using Z-track.

'''Answer:''' 3 (C). Ventrogluteal, at a 90 degree angle, using Z-track.

''Rationale:'' The ventrogluteal site accommodates up to about 3 mL in an adult, is free of major nerves and large vessels, and is preferred for viscous or irritating medications. Z-track technique seals the medication in the muscle and prevents tracking into subcutaneous tissue. The deltoid in option 1 holds only about 1 mL and is too small for this volume. The dorsogluteal site in option 2 is no longer recommended because of sciatic nerve injury risk. Intramuscular injections are given at 90 degrees, not 45 degrees, so option 4 is incorrect in technique even though the vastus lateralis is an acceptable site.

==Question 13==
A client with a T4 spinal cord injury suddenly develops a pounding headache, blood pressure of 196/110 mm Hg, a pulse of 48 beats per minute, flushing of the face, and cool pale skin below the level of injury. Which action should the nurse take '''first'''?
# Place the client in a sitting position with the head of the bed elevated.
# Assess the urinary catheter tubing for kinks or obstruction.
# Administer the prescribed antihypertensive medication.
# Notify the provider of the client's blood pressure.

'''Answer:''' 1 (A). Place the client in a sitting position with the head of the bed elevated.

''Rationale:'' This is autonomic dysreflexia, a hypertensive emergency that can cause stroke or seizure. Raising the head of the bed immediately uses orthostatic pooling to lower blood pressure and takes seconds. The nurse then removes the noxious stimulus, most often a kinked or obstructed catheter, fecal impaction, or restrictive clothing, as in option 2. Option 3 follows if positioning and stimulus removal do not lower the pressure. Option 4 is necessary but not before the two immediate interventions the nurse can perform independently.

==Question 14==
A client with acute respiratory distress is receiving oxygen at 10 L/min by nonrebreather mask. The nurse observes that the reservoir bag collapses completely with each inspiration. Which action should the nurse take?
# Change the client to a Venturi mask at 40 percent.
# Increase the oxygen flow rate until the bag remains partially inflated.
# Remove one of the one-way exhalation valves from the mask.
# Document the finding as an expected function of the device.

'''Answer:''' 2 (B). Increase the oxygen flow rate until the bag remains partially inflated.

''Rationale:'' Complete collapse of the reservoir bag means the client's inspiratory demand exceeds the delivered flow, so room air is being entrained and the delivered oxygen concentration falls. Increasing the flow, typically to 15 L/min or higher as needed, restores the reservoir. Option 1 lowers the delivered concentration in a client with acute severe hypoxemia. Option 3 destroys the device's ability to deliver a high concentration and is unsafe. Option 4 is incorrect, since the bag should never fully collapse.

==Question 15==
A registered nurse is planning assignments on a medical unit. Which tasks may the nurse appropriately delegate to a licensed practical nurse? '''Select all that apply.'''
# Performing a sterile dressing change on a stable surgical wound.
# Inserting an indwelling urinary catheter for a client with retention.
# Completing the admission assessment and initiating the plan of care for a new client.
# Administering an intramuscular antibiotic to a stable client.
# Administering the first unit of packed red blood cells.
# Reinforcing preoperative teaching that the registered nurse has already provided.

'''Answer:''' 1, 2, 4, and 6 (A, B, D, F).

''Rationale:'' Established sterile dressing changes, urinary catheterization, and intramuscular medication administration for stable clients fall within licensed practical nurse scope in most jurisdictions, as does reinforcing teaching the registered nurse initiated. Option 3 is retained by the registered nurse, because initial comprehensive assessment, analysis, and care planning are not delegable. Option 5 is retained by the registered nurse in most jurisdictions, since blood product administration requires ongoing evaluation for transfusion reaction. Scope varies by state nurse practice act, and the exam applies the most restrictive common standard.

[[Category:Nursing Skills and Procedures]]
[[Category:Registered Nurse (NCLEX-RN)]]
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