Reduction of Risk Potential 2

Question 1

A client's morning labs show a serum sodium of 122 mEq/L. Which assessment finding does the nurse anticipate?

Accepted Answer

Confusion, lethargy, and headache

Answer

Dry mucous membranes and poor skin turgor

Answer

Peaked T-waves on ECG

Answer

Positive Chvostek's and Trousseau's signs

Question 2

A nurse is preparing a client for a lumbar puncture. Which position should the nurse assist the client into?

Accepted Answer

Lateral recumbent with back arched and knees drawn to chest

Answer

Prone with a pillow under the abdomen

Answer

Supine with the head of bed elevated 30 degrees

Answer

Sitting upright leaning forward over a pillow

Question 3

A post-operative client has a nasogastric (NG) tube. Before administering medications through the tube, which action is the nurse's priority?

Accepted Answer

Verify tube placement by checking gastric aspirate pH

Answer

Flush the tube with 30 mL of water

Answer

Crush all medications and mix them together

Answer

Position the client supine before administration

Question 4

A nurse is monitoring a client receiving a blood transfusion who develops chills, fever (38.9°C), and flank pain 20 minutes into the infusion. Which action should the nurse take first?

Accepted Answer

Stop the transfusion immediately

Answer

Slow the infusion rate and notify the provider

Answer

Administer diphenhydramine (Benadryl) IV

Answer

Obtain a stat BMP and CBC

Question 5

A nurse receives a lab result showing a client's INR is 4.8 while on warfarin therapy for atrial fibrillation. Which action is most appropriate?

Accepted Answer

Hold warfarin and notify the provider immediately

Answer

Administer the next scheduled warfarin dose as ordered

Answer

Administer aspirin 81 mg to reduce clotting risk

Answer

Encourage the client to increase leafy green vegetable intake

Question 6

A client is scheduled for a bronchoscopy. Which pre-procedure nursing action is essential?

Accepted Answer

Verify the client has been NPO for at least 6–8 hours

Answer

Administer a Fleet enema to cleanse the bowel

Answer

Apply a topical antibiotic ointment to the nares

Answer

Place the client in a prone position for baseline assessment