ADVANCED CLINICAL NURSING
SKILLS AND TECHNIQUES REVIEW
QUESTIONS AND CORRECT ANSWERS
LATEST UPDATE
1. A nurse is assessing a patient using the Glasgow Coma Scale (GCS). The patient opens eyes
to pain, makes incomprehensible sounds, and withdraws from pain. What is the GCS score?
A. GCS 10
B. GCS 9
C. GCS 8
D. GCS 7
Answer: C
Conceptual Explanation: Eye opening to pain = 2; Incomprehensible sounds = 2;
Withdraws from pain = 4. Total score is 8.
2. When removing Personal Protective Equipment (PPE) after caring for a patient on contact
and droplet precautions, which item should be removed first?
A. Gloves
B. Gown
C. Mask or respirator
,D. Goggles or face shield
Answer: A
Conceptual Explanation: Gloves are considered the most contaminated and should be
removed first to prevent cross-contamination.
3. Which nursing intervention is the highest priority for a patient exhibiting signs of
Autonomic Dysreflexia?
A. Administering antihypertensive medication
B. Checking the patient for bladder distension
C. Placing the patient in a high-Fowler position
D. Performing a digital rectal exam to check for impaction
Answer: C
Conceptual Explanation: Elevating the head of the bed to a sitting position (high-Fowler)
helps decrease blood pressure via orthostatic changes and is the first priority.
4. During the administration of a large-volume cleansing enema, the patient complains of
abdominal cramping. What is the nurse’s next action?
A. Lower the enema container to slow the rate of flow
B. Stop the procedure immediately and notify the physician
C. Advance the rectal tube further into the colon
D. Encourage the patient to take shallow, rapid breaths
, Answer: A
Conceptual Explanation: Lowering the container slows the infusion rate, which typically
relieves cramping while allowing the procedure to continue.
5. A patient with a chest tube has continuous bubbling in the water-seal chamber. How
should the nurse interpret this finding?
A. This is a normal finding if the patient has a pneumothorax
B. The suction pressure is set too high
C. There is a likely air leak in the drainage system
D. The lung has fully re-expanded
Answer: C
Conceptual Explanation: Continuous bubbling in the water-seal chamber indicates an air
leak between the patient and the drainage system.
6. Which anatomical landmark is used when administering an intramuscular injection into the
ventrogluteal site?
A. The greater trochanter and anterior superior iliac spine
B. The acromion process
C. The posterior superior iliac spine
D. The vastus lateralis muscle
Answer: A
SKILLS AND TECHNIQUES REVIEW
QUESTIONS AND CORRECT ANSWERS
LATEST UPDATE
1. A nurse is assessing a patient using the Glasgow Coma Scale (GCS). The patient opens eyes
to pain, makes incomprehensible sounds, and withdraws from pain. What is the GCS score?
A. GCS 10
B. GCS 9
C. GCS 8
D. GCS 7
Answer: C
Conceptual Explanation: Eye opening to pain = 2; Incomprehensible sounds = 2;
Withdraws from pain = 4. Total score is 8.
2. When removing Personal Protective Equipment (PPE) after caring for a patient on contact
and droplet precautions, which item should be removed first?
A. Gloves
B. Gown
C. Mask or respirator
,D. Goggles or face shield
Answer: A
Conceptual Explanation: Gloves are considered the most contaminated and should be
removed first to prevent cross-contamination.
3. Which nursing intervention is the highest priority for a patient exhibiting signs of
Autonomic Dysreflexia?
A. Administering antihypertensive medication
B. Checking the patient for bladder distension
C. Placing the patient in a high-Fowler position
D. Performing a digital rectal exam to check for impaction
Answer: C
Conceptual Explanation: Elevating the head of the bed to a sitting position (high-Fowler)
helps decrease blood pressure via orthostatic changes and is the first priority.
4. During the administration of a large-volume cleansing enema, the patient complains of
abdominal cramping. What is the nurse’s next action?
A. Lower the enema container to slow the rate of flow
B. Stop the procedure immediately and notify the physician
C. Advance the rectal tube further into the colon
D. Encourage the patient to take shallow, rapid breaths
, Answer: A
Conceptual Explanation: Lowering the container slows the infusion rate, which typically
relieves cramping while allowing the procedure to continue.
5. A patient with a chest tube has continuous bubbling in the water-seal chamber. How
should the nurse interpret this finding?
A. This is a normal finding if the patient has a pneumothorax
B. The suction pressure is set too high
C. There is a likely air leak in the drainage system
D. The lung has fully re-expanded
Answer: C
Conceptual Explanation: Continuous bubbling in the water-seal chamber indicates an air
leak between the patient and the drainage system.
6. Which anatomical landmark is used when administering an intramuscular injection into the
ventrogluteal site?
A. The greater trochanter and anterior superior iliac spine
B. The acromion process
C. The posterior superior iliac spine
D. The vastus lateralis muscle
Answer: A
