,Q1 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
A patient with a history of chronic pain is prescribed a transdermal fentanyl patch.
Which nursing intervention is most critical to prevent adverse effects?
A. Apply the patch to the upper back to maximize absorption
B. Remove the old patch and cleanse the site before applying a new one CORRECT
C. Apply the patch immediately after removing it from the package
D. Document the location of the patch on the medication administration record
RATIONALE: Removing the old patch and cleansing the site prevents accumulation of fentanyl
and skin irritation, reducing risk of overdose. Applying to the upper back is not recommended;
avoid hairy or irritated areas. Immediate application is standard but not the most critical.
Documentation is important but secondary to safety.
Q2 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
A patient is receiving a blood transfusion. Which assessment finding requires
immediate action by the nurse?
A. Temperature increase of 1°C (1.8°F) after 15 minutes CORRECT
B. Slight flushing of the face
C. Blood pressure from 110/70 to 100/65
D. Patient reports feeling 'a bit cold'
RATIONALE: A temperature increase of 1°C or more is a sign of a febrile transfusion reaction,
which requires stopping the transfusion. Flushing may be mild, but temperature elevation is more
indicative of a reaction. Mild BP drop and feeling cold are not as critical.
Page 2
,Q3 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
In a disaster triage situation, which patient should be tagged as 'red' (immediate)
according to START triage?
A. Patient with a minor fracture and stable vital signs
B. Patient with a sucking chest wound and respiratory distress CORRECT
C. Patient with a severe head injury and no pulse
D. Patient with a sprained ankle and walking
RATIONALE: A sucking chest wound with respiratory distress requires immediate intervention to
save life, hence 'red'. Minor fracture and sprain are 'green'. No pulse indicates 'black' (deceased).
Q4 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
A patient is prescribed an NG tube for enteral feeding. Which action demonstrates
correct verification of tube placement?
A. Auscultate air insufflation over the epigastrium
B. Check the pH of aspirated gastric contents (pH 5.5)
C. Confirm placement by X-ray after initial insertion CORRECT
D. Observe for coughing or respiratory distress during insertion
RATIONALE: X-ray is the gold standard for confirming NG tube placement. pH testing is useful
but not definitive. Auscultation is unreliable. Observing for respiratory distress is important during
insertion but not a verification method.
Page 3
, Q5 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
A patient with a urinary catheter develops a fever and cloudy urine. Which action
is a priority?
A. Increase fluid intake to flush the catheter
B. Collect a urine specimen for culture and sensitivity CORRECT
C. Administer antipyretics as prescribed
D. Replace the catheter with a new one immediately
RATIONALE: A fever and cloudy urine suggest a catheter-associated urinary tract infection
(CAUTI). The priority is to obtain a urine specimen for culture to guide antibiotic therapy.
Increasing fluids and antipyretics are supportive but not primary. Catheter replacement may be
needed but is not the first action.
Q6 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
Which ethical principle is most directly violated when a nurse shares a patient's
health information with a family member without consent?
A. Autonomy
B. Beneficence
C. Confidentiality CORRECT
D. Justice
RATIONALE: Confidentiality is the principle that protects patient privacy. Sharing information
without consent violates this. Autonomy respects patient choices, beneficence promotes good,
justice ensures fairness-none are directly violated in this scenario.
Page 4
A patient with a history of chronic pain is prescribed a transdermal fentanyl patch.
Which nursing intervention is most critical to prevent adverse effects?
A. Apply the patch to the upper back to maximize absorption
B. Remove the old patch and cleanse the site before applying a new one CORRECT
C. Apply the patch immediately after removing it from the package
D. Document the location of the patch on the medication administration record
RATIONALE: Removing the old patch and cleansing the site prevents accumulation of fentanyl
and skin irritation, reducing risk of overdose. Applying to the upper back is not recommended;
avoid hairy or irritated areas. Immediate application is standard but not the most critical.
Documentation is important but secondary to safety.
Q2 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
A patient is receiving a blood transfusion. Which assessment finding requires
immediate action by the nurse?
A. Temperature increase of 1°C (1.8°F) after 15 minutes CORRECT
B. Slight flushing of the face
C. Blood pressure from 110/70 to 100/65
D. Patient reports feeling 'a bit cold'
RATIONALE: A temperature increase of 1°C or more is a sign of a febrile transfusion reaction,
which requires stopping the transfusion. Flushing may be mild, but temperature elevation is more
indicative of a reaction. Mild BP drop and feeling cold are not as critical.
Page 2
,Q3 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
In a disaster triage situation, which patient should be tagged as 'red' (immediate)
according to START triage?
A. Patient with a minor fracture and stable vital signs
B. Patient with a sucking chest wound and respiratory distress CORRECT
C. Patient with a severe head injury and no pulse
D. Patient with a sprained ankle and walking
RATIONALE: A sucking chest wound with respiratory distress requires immediate intervention to
save life, hence 'red'. Minor fracture and sprain are 'green'. No pulse indicates 'black' (deceased).
Q4 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
A patient is prescribed an NG tube for enteral feeding. Which action demonstrates
correct verification of tube placement?
A. Auscultate air insufflation over the epigastrium
B. Check the pH of aspirated gastric contents (pH 5.5)
C. Confirm placement by X-ray after initial insertion CORRECT
D. Observe for coughing or respiratory distress during insertion
RATIONALE: X-ray is the gold standard for confirming NG tube placement. pH testing is useful
but not definitive. Auscultation is unreliable. Observing for respiratory distress is important during
insertion but not a verification method.
Page 3
, Q5 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
A patient with a urinary catheter develops a fever and cloudy urine. Which action
is a priority?
A. Increase fluid intake to flush the catheter
B. Collect a urine specimen for culture and sensitivity CORRECT
C. Administer antipyretics as prescribed
D. Replace the catheter with a new one immediately
RATIONALE: A fever and cloudy urine suggest a catheter-associated urinary tract infection
(CAUTI). The priority is to obtain a urine specimen for culture to guide antibiotic therapy.
Increasing fluids and antipyretics are supportive but not primary. Catheter replacement may be
needed but is not the first action.
Q6 APPLY THE NURSING PROCESS TO COMPLEX CLINICAL SCENARIOS
Which ethical principle is most directly violated when a nurse shares a patient's
health information with a family member without consent?
A. Autonomy
B. Beneficence
C. Confidentiality CORRECT
D. Justice
RATIONALE: Confidentiality is the principle that protects patient privacy. Sharing information
without consent violates this. Autonomy respects patient choices, beneficence promotes good,
justice ensures fairness-none are directly violated in this scenario.
Page 4
