Central lines carry the highest-consequence errors on a med-surg unit. These questions cover the CLABSI prevention bundle, sterile dressing changes and flushing, recognising an air embolism and what to do in that first minute, occlusion troubleshooting, and the positioning that makes line removal safe.
Question 1
52 of 125. A nurse observes four situations: Situation 1: Patient ambulating in hall suddenly clutches chest, appears pale. Situation 2: Visitor trips and falls, complaining of wrist pain. Situation 3: IV pump for a patient receiving potassium replacement alarms "air in line". Situation 4: Patient's lunch tray contains nuts, but the patient has a documented nut allergy. Which situation necessitates the nurse's most rapid response?
- A) A) The ambulating patient clutching their chest and appearing pale.✓
- B) B) The visitor who fell and is complaining of wrist pain.
- C) C) The IV pump alarming air in line during potassium infusion.
- D) D) The lunch tray containing nuts for a patient with a nut allergy.
Show rationale
A patient clutching their chest and appearing pale strongly suggests acute cardiac ischemia or other serious cardiopulmonary event (e.g., PE), demanding immediate assessment and intervention (ABCs). A visitor fall with wrist pain (B) is important but less critical. A small air-in-line alarm (C) needs clearing but poses minimal immediate risk; significant air embolus is rare. Preventing ingestion of nuts (D) is crucial but can often be managed by removing the tray before the patient eats, allowing slightly more time than a potential cardiac arrest.
Question 2
5 of 125. During a mass casualty event, four agricultural workers exposed to an unknown liquid chemical report muscle twitching, salivation, and blurred vision. Triage tags indicate all have pinpoint pupils and wheezing. Which decontamination action takes precedence?
- A) A) Remove contaminated clothing and flush skin with copious water✓
- B) B) Administer intramuscular atropine and pralidoxime immediately
- C) C) Apply dry absorbent powder to neutralize liquid residues
- D) D) Provide high-flow oxygen via non-rebreather mask
Show rationale
Symptoms indicate organophosphate poisoning (nerve agents). Skin decontamination must precede medical treatment to prevent provider exposure and ongoing absorption (CDC chemical guidelines). Removing clothing eliminates 80-90% of contamination; water flushing dilutes toxin. Atropine (B) is critical but shouldn't delay decontamination. Dry powder (C) may worsen absorption. Oxygen (D) addresses respiratory effects but ignores ongoing dermal exposure. The mass casualty context requires efficient decontamination to protect both patients and responders.
Question 3
15 of 125. A medical-surgical nurse identifies a 15% increase in catheter-associated UTIs. The Magnet®-recognized hospital's policy encourages nurse-led research. The nurse has preliminary data but lacks statistical analysis skills. Which resource aligns with Structural Empowerment principles?
- A) A) Requesting the infection control department conduct formal data analysis
- B) B) Partnering with a nurse researcher for mentorship in data interpretation✓
- C) C) Presenting raw data to the ethics committee for quality recommendations
- D) D) Attending a national conference on evidence-based infection control
Show rationale
Structural Empowerment provides resources for professional growth (Magnet® Component 2). Option B offers mentorship (skill-building cue) while maintaining nurse ownership of the project (autonomy cue). Option A transfers responsibility away from the nurse. Option C involves an inappropriate committee, delaying action. Option D provides general education but no direct support for the immediate project. Magnet® hospitals foster staff development through accessible experts, not delegation or passive learning.
Question 4
30 of 125. During administration of IV potassium chloride 40 mEq in 1000 mL normal saline via a peripheral IV, the nurse notes significant swelling around the site without pain or change in skin temperature. Blood return is absent. What is the priority nursing intervention?
- A) A) Apply a warm compress and monitor the site closely.
- B) B) Stop the infusion immediately and remove the catheter.✓
- C) C) Slow the infusion rate and reassess the site in 15 minutes.
- D) D) Aspirate the catheter and attempt to flush with normal saline.
Show rationale
Concentrated potassium chloride (KCl) is a severe irritant/vesicant. Absent blood return and significant swelling confirm infiltration/extravasation, requiring immediate cessation to prevent severe tissue necrosis (Cue: High-concentration vesicant, signs of infiltration). Pain is not always present. Option A (heat) is inappropriate for KCl infiltration. Option C (slowing infusion) delays necessary intervention while more irritant enters tissue. Option D (aspirate/flush) risks pushing more KCl into tissue and is not standard for peripheral infiltration management; removal is key.
Question 5
58 of 125. A new nurse uses non-sterile tape to secure a central line after dressing change. Which educational correction reflects CLABSI prevention principles?
- A) A) Use sterile tape only if the dressing loosens before 7 days.
- B) B) Secure lines with sutures or sterile tape to maintain integrity.✓
- C) C) Sterile tape isn't needed since dressings are self-adhesive.
- D) D) Apply only sterile tape under transparent dressings when damp.
Show rationale
CDC guidelines state line stabilization (sutures/sterile tape) prevents movement-related contamination. Option B reinforces this standard. Option A delays intervention, risking dislodgement. Option C ignores that self-adhesive dressings may still require securement. Option D limits tape use incorrectly. B provides accurate competency feedback, addressing the observed practice error.
Question 6
84 of 125. A patient with a T8 spinal cord injury and autonomic dysreflexia triggers during repositioning. Which action prioritizes safety?
- A) A) Lower head of bed and check catheter✓
- B) B) Complete repositioning rapidly
- C) C) Administer PRN antihypertensive
- D) D) Return to original position
Show rationale
Autonomic dysreflexia requires immediate upright positioning to lower BP and bladder assessment, as catheter issues are common triggers. Option B exacerbates hypertension. Option C addresses symptoms but not the cause. Option D maintains the noxious stimulus. Paraplegia guidelines emphasize positional correction and trigger removal before medication.
Question 7
97 of 125. During a TJC accreditation visit, a nurse observes an unlabeled sterile field in a procedure room where a colleague is preparing for a catheter insertion. Which action demonstrates adherence to TJC's infection control standards?
- A) A) Labeling the field immediately with time and date
- B) B) Reminding the colleague to label it after the procedure
- C) C) Replacing the field with a new pre-labeled kit✓
- D) D) Reporting the lapse to the charge nurse post-procedure
Show rationale
TJC standards require immediate correction of unlabeled sterile fields to prevent infections. Option C resolves both cues (unlabeled field, active procedure) by ensuring sterility with a compliant kit. Option A contaminates the field by adding labels mid-procedure. Option B delays action, risking contamination. Option D neglects direct intervention despite imminent patient risk.
Question 8
120 of 125. An epidural pump alarms for "downstream occlusion" in a patient with sudden pain relief loss. The insertion site is intact without leakage. Which troubleshooting step comes first?
- A) A) Flush the catheter with preservative-free saline gently.
- B) B) Verify tubing connections and check for kinks throughout.✓
- C) C) Replace the entire infusion set and filter immediately.
- D) D) Notify anesthesia for catheter dye study evaluation.
Show rationale
Occlusion alarms require mechanical checks first (B) per pump protocols. Flushing (A) risks intrathecal injection if catheter migrated. Replacing tubing (C) is premature before inspection. Dye studies (D) follow basic troubleshooting. Intact site rules out disconnection, making kinks/loose connections the likely issue. Pain loss confirms delivery failure, prioritizing physical assessment over invasive steps.
Question 9
124 of 125. While preparing a body after brain death, the nurse learns the patient is a potential organ donor. Which action violates UNOS protocol for post-mortem care?
- A) A) Lowering the head of the bed to 15 degrees to preserve corneal tissue
- B) B) Leaving urinary catheter in place until procurement team assessment
- C) C) Applying ice packs directly to the skin to slow tissue deterioration✓
- D) D) Delaying bathing until after organ procurement organization evaluation
Show rationale
UNOS prohibits direct ice application (C) to prevent frostbite damage to donor organs/tissues. Slight bed elevation (A) may aid ocular viability. Maintaining catheters (B) and delaying bathing (D) preserve access and sterility. Distractors represent appropriate actions, while direct cooling risks violating organ viability standards.
Question 10
63 of 125. A patient receiving morphine PCA develops urticaria and facial flushing. History includes shellfish allergy. Which intervention should be prioritized before continuing PCA?
- A) A) Switch PCA opioid to hydromorphone immediately
- B) B) Administer diphenhydramine and reassess in 30 minutes
- C) C) Evaluate for concurrent respiratory distress or hypotension✓
- D) D) Review medication records for recent iodine contrast exposure
Show rationale
Urticaria with allergy history suggests anaphylaxis risk. Airway/hemodynamic assessment is critical per ACLS anaphylaxis protocols before symptom management. Antihistamines (B) treat symptoms but delay identifying life-threatening reactions. Opioid switching (A) is premature without confirming allergy versus side effect. Contrast review (D) is irrelevant to PCA-related allergy evaluation. Flushing and shellfish allergy are cues for rapid anaphylaxis screening.
