An elderly bedridden patient has an area of nonblanchable redness over the sacrum with intact skin. Which planned action should the nurse remove from the care plan?

Using a pressure-redistributing mattress

Turning the patient every 2 hours

A young man brought in after a road traffic accident dies 30 minutes after arrival despite resuscitation. The case is registered as medico-legal. How should the nurse handle the tubes and lines while performing last offices?

Leave tubes and lines in place and hand over as per MLC protocol

Remove every tube and line and dress each site neatly

Remove the IV cannula but leave the endotracheal tube

Remove all tubes so the family can view the body

IV therapy, oxygen, wound care and comfort

18 AIIMS NORCET (Nursing Officer) practice questions on IV therapy, oxygen, wound care and comfort, part of Fundamentals of Nursing. The first 18 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Easy
Swelling, coolness, pallor and tightness of the skin around a peripheral IV site, with a slowing infusion, indicate:
1. ACirculatory overload
2. BInfiltration
3. CAir embolism
4. DPhlebitis
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Answer: B · Infiltration
Infiltration is leakage of a non-vesicant fluid into the tissue around the cannula. The fluid is at room temperature and stretches the skin, so the site is cool, pale, swollen and tight, and the flow slows. The nurse stops the infusion, removes the cannula, elevates the limb and resites the line in the other arm. A vesicant drug leaking out is called extravasation and needs the hospital's extravasation protocol.
- A: Circulatory overload gives raised BP, distended neck veins and crackles, not a local sign.
- C: Air embolism causes sudden breathlessness, chest pain and hypotension, not a local swelling.
- D: Phlebitis makes the vein red, warm and tender, often with a palpable cord.
Question 2 · Easy
In Kubler-Ross's model of grieving, which stage immediately follows anger?
1. ADenial
2. BBargaining
3. CAcceptance
4. DDepression
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Answer: B · Bargaining
Kubler-Ross described five stages: denial, anger, bargaining, depression and acceptance. In bargaining the person tries to postpone the loss, often by making promises such as 'if I can just see my daughter married'. People do not always pass through the stages in a fixed order. The nurse listens without challenging the bargain and allows the person to express feelings.
- A: Denial is the first stage, before anger.
- C: Acceptance is the last stage.
- D: Depression comes after bargaining, once the loss can no longer be postponed.
Question 3 · Medium
An elderly bedridden patient has an area of nonblanchable redness over the sacrum with intact skin. Which planned action should the nurse remove from the care plan?
1. AUsing a pressure-redistributing mattress
2. BTurning the patient every 2 hours
3. CKeeping the skin clean and dry
4. DMassaging the reddened area
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Answer: D · Massaging the reddened area
Nonblanchable erythema of intact skin is a stage 1 pressure injury. Massaging reddened bony areas is harmful: it can damage the already injured capillaries and deeper tissue. Care focuses on relieving pressure by repositioning, using support surfaces, managing moisture and improving nutrition. The nurse documents the area and reassesses it at each turn.
- A: Support surfaces spread pressure and are recommended.
- B: Regular repositioning relieves pressure and is the core preventive measure.
- C: Clean, dry skin lowers moisture damage and is recommended.
Question 4 · Hard
A young man brought in after a road traffic accident dies 30 minutes after arrival despite resuscitation. The case is registered as medico-legal. How should the nurse handle the tubes and lines while performing last offices?
1. ARemove every tube and line and dress each site neatly
2. BRemove the IV cannula but leave the endotracheal tube
3. CRemove all tubes so the family can view the body
4. DLeave tubes and lines in place and hand over as per MLC protocol
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Answer: D · Leave tubes and lines in place and hand over as per MLC protocol
In a medico-legal case a post-mortem examination is required, and the tubes, lines and drains may be evidence of the treatment given. They are left in place, capped or spigotted, and recorded. The body, belongings and documents are handed over to the police or mortuary according to the hospital's MLC protocol. In a non-MLC death, tubes are usually removed during last offices unless the policy says otherwise.
- A: Removing every tube is routine only when no post-mortem is required.
- B: There is no rule to remove some devices and keep others in an MLC death.
- C: Family viewing does not override the legal need for an unaltered body.
Question 5 · Easy
The highest oxygen flow rate generally recommended through a standard adult nasal cannula is:
1. A15 L/min
2. B10 L/min
3. C2 L/min
4. D6 L/min
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Answer: D · 6 L/min
A standard nasal cannula is used at 1-6 L/min and gives an FiO2 of roughly 24-44%. Above about 6 L/min the extra flow adds little oxygen, because the nasopharynx acts as a small reservoir that is already full. Higher flows dry and irritate the nasal mucosa and can cause nosebleeds. A patient who needs more oxygen should move to a mask device.
- A: 15 L/min is the flow used with a non-rebreather mask.
- B: 10 L/min is a mask flow and would dry the nasal mucosa.
- C: 2 L/min is a common low setting, not the upper limit.
Question 6 · Hard
A patient has Braden score 11. Over the heel is a wound whose base is fully covered with yellow slough, so its depth cannot be seen. How should the nurse document this pressure injury?
1. AStage 3 pressure injury
2. BUnstageable pressure injury
3. CStage 4 pressure injury
4. DDeep tissue pressure injury
Answer and explanation in LearnFree account
Question 7 · Easy
Total scores on the Braden scale for predicting pressure injury risk range from:
1. A0 to 10
2. B15 to 45
3. C6 to 23
4. D4 to 20
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Question 8 · Hard
A 4-year-old is ordered 300 mL of IV fluid over 6 hours through a paediatric microdrip set (60 drops/mL). What drip rate should the nurse set?
1. A17 drops/min
2. B300 drops/min
3. C5 drops/min
4. D50 drops/min
Answer and explanation in LearnFree account
Question 9 · Medium
A patient is receiving oxygen through a non-rebreather mask. The nurse sees the reservoir bag collapse completely each time the patient breathes in. The correct action is to:
1. ALoosen the mask strap
2. BRemove the one-way valves
3. CIncrease the oxygen flow rate
4. DChange to a nasal cannula
Answer and explanation in LearnFree account
Question 10 · Easy
A sacral wound shows full-thickness skin loss with visible subcutaneous fat, but no bone, tendon or muscle is exposed and the base can be seen. By the NPIAP system this is a:
1. AStage 4 pressure injury
2. BStage 3 pressure injury
3. CStage 2 pressure injury
4. DUnstageable pressure injury
Answer and explanation in LearnFree account
Question 11 · Medium
A trauma patient with heavy blood loss needs rapid fluid and blood replacement through a peripheral line. Which cannula should the nurse choose?
1. A20 G (pink)
2. B22 G (blue)
3. C16 G (grey)
4. D24 G (yellow)
Answer and explanation in LearnFree account
Question 12 · Medium
Applying a hot water bag to the abdomen is contraindicated in a patient with suspected:
1. APrimary dysmenorrhoea
2. BChronic low back pain
3. CAbdominal muscle cramps
4. DAcute appendicitis
Answer and explanation in LearnFree account
Question 13 · Medium
A patient with COPD and chronic carbon dioxide retention needs a precise, controlled oxygen concentration. The most suitable device is:
1. AA non-rebreather mask
2. BA Venturi mask
3. CA nasal cannula at 6 L/min
4. DA simple face mask
Answer and explanation in LearnFree account
Question 14 · Medium
A 2-year-old child is restless after a hernia repair and cannot describe the pain. The most appropriate tool for assessing the pain is the:
1. AVisual analogue scale
2. BMcGill Pain Questionnaire
3. CNumeric rating scale
4. DFLACC scale
Answer and explanation in LearnFree account
Question 15 · Easy
Cold application is most appropriate for which patient?
1. ASuperficial thrombophlebitis of the forearm
2. BA low back muscle spasm of three days
3. CMorning joint stiffness in chronic arthritis
4. DAn ankle sprain within the first 24 hours
Answer and explanation in LearnFree account
Question 16 · Hard
A 68-year-old man with long-standing COPD was put on a simple face mask at 8 L/min in casualty. An hour later he is drowsy and hard to rouse, with respiratory rate 10/min and SpO2 98%. What should the nurse do first?
1. ALet him sleep and recheck observations in an hour
2. BChange to a non-rebreather mask at 15 L/min
3. CReduce oxygen to a target SpO2 of 88-92% and inform the doctor
4. DLay him flat and remove the mask completely
Answer and explanation in LearnFree account
Question 17 · Hard
A bag of 1,500 mL normal saline is running at 25 drops/min through a set that delivers 15 drops/mL. How long will the bag take to finish?
1. A60 hours
2. B10 hours
3. C15 hours
4. D20 hours
Answer and explanation in LearnFree account
Question 18 · Medium
Sleepwalking and night-time bed-wetting in children typically occur during:
1. ADeep slow-wave NREM sleep
2. BRapid eye movement sleep
3. CLight stage 1 NREM sleep
4. DBrief awakenings near morning
Answer and explanation in LearnFree account

IV therapy, oxygen, wound care and comfort

Swelling, coolness, pallor and tightness of the skin around a peripheral IV site, with a slowing infusion, indicate:

In Kubler-Ross's model of grieving, which stage immediately follows anger?

An elderly bedridden patient has an area of nonblanchable redness over the sacrum with intact skin. Which planned action should the nurse remove from the care plan?

A young man brought in after a road traffic accident dies 30 minutes after arrival despite resuscitation. The case is registered as medico-legal. How should the nurse handle the tubes and lines while performing last offices?

The highest oxygen flow rate generally recommended through a standard adult nasal cannula is:

A patient has Braden score 11. Over the heel is a wound whose base is fully covered with yellow slough, so its depth cannot be seen. How should the nurse document this pressure injury?

Total scores on the Braden scale for predicting pressure injury risk range from:

A 4-year-old is ordered 300 mL of IV fluid over 6 hours through a paediatric microdrip set (60 drops/mL). What drip rate should the nurse set?

A patient is receiving oxygen through a non-rebreather mask. The nurse sees the reservoir bag collapse completely each time the patient breathes in. The correct action is to:

A sacral wound shows full-thickness skin loss with visible subcutaneous fat, but no bone, tendon or muscle is exposed and the base can be seen. By the NPIAP system this is a:

A trauma patient with heavy blood loss needs rapid fluid and blood replacement through a peripheral line. Which cannula should the nurse choose?

Applying a hot water bag to the abdomen is contraindicated in a patient with suspected:

A patient with COPD and chronic carbon dioxide retention needs a precise, controlled oxygen concentration. The most suitable device is:

A 2-year-old child is restless after a hernia repair and cannot describe the pain. The most appropriate tool for assessing the pain is the:

Cold application is most appropriate for which patient?

A 68-year-old man with long-standing COPD was put on a simple face mask at 8 L/min in casualty. An hour later he is drowsy and hard to rouse, with respiratory rate 10/min and SpO2 98%. What should the nurse do first?

A bag of 1,500 mL normal saline is running at 25 drops/min through a set that delivers 15 drops/mL. How long will the bag take to finish?

Sleepwalking and night-time bed-wetting in children typically occur during: