NACE Reduction of Risk Potential 3

Question 1

A nurse is reviewing arterial blood gas results: pH 7.30, PaCO2 50 mmHg, HCO3 24 mEq/L. Which acid-base imbalance does this represent?

Accepted Answer

Respiratory acidosis

Answer

Metabolic acidosis

Answer

Metabolic alkalosis

Answer

Respiratory alkalosis

Question 2

A patient is at risk for falls. Which intervention is most effective for fall prevention?

Accepted Answer

Ensuring the call light is within reach and the bed is in the lowest position

Answer

Keeping all four side rails raised at all times

Answer

Applying a vest restraint during all waking hours

Answer

Administering sedation at night to prevent wandering

Question 3

A nurse is preparing to transfuse packed red blood cells. What is the maximum time allowed for a single unit of PRBC to infuse?

Accepted Answer

4 hours

Answer

1 hour

Answer

2 hours

Answer

8 hours

Question 4

A nurse observes that a patient's Jackson-Pratt (JP) drain has changed from serosanguineous to bright red output. What should the nurse do?

Accepted Answer

Notify the surgeon, as this may indicate active bleeding

Answer

Empty the drain and record the output as expected

Answer

Remove the drain immediately

Answer

Clamp the drain and reposition the patient

Question 5

A patient is receiving continuous pulse oximetry. The reading shows SpO2 of 78% but the patient appears comfortable and in no distress. What should the nurse assess first?

Accepted Answer

Check the probe placement and patient's perfusion status

Answer

Administer high-flow oxygen immediately

Answer

Call a rapid response team

Answer

Obtain an arterial blood gas immediately

Question 6

A nurse is monitoring a patient receiving a blood transfusion who develops urticaria (hives) without other symptoms. What is the appropriate initial action?

Accepted Answer

Stop the transfusion, administer an antihistamine per protocol, and monitor

Answer

Stop the transfusion and return the blood to the blood bank

Answer

Continue the transfusion since hives are a minor reaction

Answer

Administer epinephrine and call a code