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

The low pH (acidotic), elevated PaCO2 (respiratory cause), and normal HCO3 (no metabolic compensation) indicate uncompensated respiratory acidosis.

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

Ensuring the call light is within reach and the bed is in the lowest position are evidence-based fall prevention strategies that maintain patient dignity and independence.

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

Packed red blood cells must be infused within 4 hours of removal from the blood bank refrigerator to minimize the risk of bacterial proliferation.

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

A change from serosanguineous to bright red drainage in a JP drain suggests active bleeding at the surgical site and requires immediate physician notification.

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

When the pulse oximetry reading does not match the clinical picture, the nurse should first troubleshoot the equipment by checking probe placement, perfusion, and potential interfering factors.

Nursing Acceleration Challenge Exam (NACE) I PN-RN Practice Test

Nursing Acceleration Challenge Exam (NACE) I PN-RN Practice Test

NACE Reduction of Risk Potential 3