CLINICAL SKILLS EXAM #3
QUESTIONS AND ANSWERS
While receiving a blood transfusion, your patient develops chills, tachycardia, and
flushing. What is your priority action?
A. Notify a health care provider
B. Insert an indwelling catheter
C. Alert the blood bank
D. Stop the transfusion - Answer-D. Stop the transfusion
The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+
intravenously over 8 hours. Which assessment finding causes you to clarify the order
with the health care provider before hanging this fluid?
A. Flat neck veins
B. Tachycardia
C. Hypotension
D. Oliguria - Answer-D. Oliguria
Your patient who has diabetic ketoacidosis is breathing rapidly and deeply.
Intravenous (IV) fluids and other treatments have just been started. What should you
do about this patient's breathing?
A. Notify her health care provider that she is hyperventilating.
B. Provide frequent oral care to keep her mucous membranes moist.
C. Ask her to breathe slower and help her to calm down and relax
D. Assess her for pain and request an order for a sedative - Answer-B. Provide
frequent oral care to keep her mucous membranes moist
Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your
shift. Which total intake should you record?
A. 700 mL
B. 900 mL
C. 1000 mL
D. 1100 mL - Answer-C. 1000 mL
The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate
do you program into the infusion pump?
A. 125 mL/hr
B. 167 mL/hr
C. 200 mL/hr
D. 1000 mL/hr - Answer-B. 167 mL/hr
The nurse is having difficulty reading a physician's order for a medication. He or she
knows that the physician is very busy and does not like to be called. What is the
most appropriate next step for the nurse to take?
, A. Call a pharmacist to interpret the order.
B. Call the physician to have the order clarified.
C. Consult the unit manager to help interpret the order.
D. Ask the unit secretary to interpret the physician's handwriting. - Answer-B. Call the
physician to have the order clarified
The patient has an order for 2 tablespoons of Milk of Magnesia. How much
medication does the nurse give him or her?
A. 2 mL
B. 5 mL
C. 16 mL
D. 30 mL - Answer-D. 30 mL
A nurse is administering eardrops to an 8-year-old patient with an ear infection. How
does the nurse pull the patient's ear when administering the medication?
A. Outward
B. Back
C. Upward and back
D. Upward and outward - Answer-D. Upward and outward
The following medications are listed on a client's medication administration record
(MAR). Which medication order should the nurse question?
1. Lasix 40 mg po, STAT
2. Ampicillin 500 mg q5hr IVPB
3. Humulin (Lente) insulin 36 units subcutaneously every day.
4. Codeine, q4-6hr, po, prn for pain. - Answer-4. Codeine, q4-6hr, po, prn for pain.
The primary care provider prescribed 5 mL of a medication to be given deep
intramuscular for a 40 year-old female who is 5'7" tall and weighs 135 pounds.
Which is the most appropriate method of administration?
1. Tuberculin syringe #25-#27 gauge, 1/4 to 5/8 inch needle.
2. Two 3 mL syringe #20-#23 gauge, 1 1/2 needle.
3. Two 2mL syringe #25 gauge 5/8 inch needle
4. Two 2 mL syringes #20-#23 gauge 1-inch needle - Answer-4. Two 2 mL syringes
#20-#23 gauge 1-inch needle
The nurse is to administer 0.75 mL of medication subcutaneously in the upper arm to
a 50-year-old 300 pound client. The nurse can grasp approximately 2 inches of the
client's tissue at the upper arm. Which is the most appropriate for the nurse to use?
1. A tuberculin syringe, #25-#27 gauge 1/4 to 5/8 inch needle.
2. Two 3 mL syringe #20-#23 gauge, 1 1/2 inch needle.
3. 2 mL syringe #25 gauge 5/8 inch needle.
4. 2 mL syringe #20-#23 gauge 1 inch needle. - Answer-
Your patient took in 200 mL of ice chips at 1450. How would this be recorded in a log
for I&O?
a. 100 mL
QUESTIONS AND ANSWERS
While receiving a blood transfusion, your patient develops chills, tachycardia, and
flushing. What is your priority action?
A. Notify a health care provider
B. Insert an indwelling catheter
C. Alert the blood bank
D. Stop the transfusion - Answer-D. Stop the transfusion
The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+
intravenously over 8 hours. Which assessment finding causes you to clarify the order
with the health care provider before hanging this fluid?
A. Flat neck veins
B. Tachycardia
C. Hypotension
D. Oliguria - Answer-D. Oliguria
Your patient who has diabetic ketoacidosis is breathing rapidly and deeply.
Intravenous (IV) fluids and other treatments have just been started. What should you
do about this patient's breathing?
A. Notify her health care provider that she is hyperventilating.
B. Provide frequent oral care to keep her mucous membranes moist.
C. Ask her to breathe slower and help her to calm down and relax
D. Assess her for pain and request an order for a sedative - Answer-B. Provide
frequent oral care to keep her mucous membranes moist
Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your
shift. Which total intake should you record?
A. 700 mL
B. 900 mL
C. 1000 mL
D. 1100 mL - Answer-C. 1000 mL
The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate
do you program into the infusion pump?
A. 125 mL/hr
B. 167 mL/hr
C. 200 mL/hr
D. 1000 mL/hr - Answer-B. 167 mL/hr
The nurse is having difficulty reading a physician's order for a medication. He or she
knows that the physician is very busy and does not like to be called. What is the
most appropriate next step for the nurse to take?
, A. Call a pharmacist to interpret the order.
B. Call the physician to have the order clarified.
C. Consult the unit manager to help interpret the order.
D. Ask the unit secretary to interpret the physician's handwriting. - Answer-B. Call the
physician to have the order clarified
The patient has an order for 2 tablespoons of Milk of Magnesia. How much
medication does the nurse give him or her?
A. 2 mL
B. 5 mL
C. 16 mL
D. 30 mL - Answer-D. 30 mL
A nurse is administering eardrops to an 8-year-old patient with an ear infection. How
does the nurse pull the patient's ear when administering the medication?
A. Outward
B. Back
C. Upward and back
D. Upward and outward - Answer-D. Upward and outward
The following medications are listed on a client's medication administration record
(MAR). Which medication order should the nurse question?
1. Lasix 40 mg po, STAT
2. Ampicillin 500 mg q5hr IVPB
3. Humulin (Lente) insulin 36 units subcutaneously every day.
4. Codeine, q4-6hr, po, prn for pain. - Answer-4. Codeine, q4-6hr, po, prn for pain.
The primary care provider prescribed 5 mL of a medication to be given deep
intramuscular for a 40 year-old female who is 5'7" tall and weighs 135 pounds.
Which is the most appropriate method of administration?
1. Tuberculin syringe #25-#27 gauge, 1/4 to 5/8 inch needle.
2. Two 3 mL syringe #20-#23 gauge, 1 1/2 needle.
3. Two 2mL syringe #25 gauge 5/8 inch needle
4. Two 2 mL syringes #20-#23 gauge 1-inch needle - Answer-4. Two 2 mL syringes
#20-#23 gauge 1-inch needle
The nurse is to administer 0.75 mL of medication subcutaneously in the upper arm to
a 50-year-old 300 pound client. The nurse can grasp approximately 2 inches of the
client's tissue at the upper arm. Which is the most appropriate for the nurse to use?
1. A tuberculin syringe, #25-#27 gauge 1/4 to 5/8 inch needle.
2. Two 3 mL syringe #20-#23 gauge, 1 1/2 inch needle.
3. 2 mL syringe #25 gauge 5/8 inch needle.
4. 2 mL syringe #20-#23 gauge 1 inch needle. - Answer-
Your patient took in 200 mL of ice chips at 1450. How would this be recorded in a log
for I&O?
a. 100 mL
